CCM Enrollment/Consent Note

Date/Time: [Documentation timestamp]

Author: [Name, credentials]

Encounter Type: [in-person / phone / video / portal message]

Participants: [Patient name]; [Caregiver/surrogate name, relationship, and legal authority if applicable] (Include caregiver/surrogate only if present. If surrogate provides consent, document legal authority such as healthcare proxy or POA.)

Reason for Note

[Brief statement establishing this as CCM enrollment/consent documentation and the context triggering the discussion, e.g., AWV, follow-up visit, outreach call, post-discharge] (One to two sentences.)

CCM Eligibility

Attestation: [Patient meets CCM eligibility criteria / Eligibility unclear / Does not meet criteria] (Confirm the patient has two or more chronic conditions expected to last at least 12 months or until death, placing the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.)

Qualifying Chronic Conditions:

• [Chronic condition] [ICD-10 code if available]
• [Chronic condition] [ICD-10 code if available]
• [Additional conditions as applicable]

[Complexity factors supporting need for care management, such as recent hospitalizations, polypharmacy, multiple specialists, adherence challenges, or psychosocial barriers] (Include only if assessed; omit entirely if not assessed.)

(If eligibility unclear or not met, include:) Note: CCM billing should not proceed until eligibility is confirmed.

Initiating Visit

[Initiating visit completed on date, visit type] or [Initiating visit required; plan to complete before CCM billing begins] or [Not applicable—established patient seen within prior 12 months] (Omit section if not applicable.)

Patient Education and Required Disclosures

(All required disclosures must be explicitly documented; do not omit or infer.)

• [CCM services explained: monthly non-face-to-face care management including care coordination, medication review, transition support, and preventive care coordination]
• [24/7 access: how to reach care team for urgent needs after-hours; designated care team member identified for routine continuity]
• [Care plan: electronic comprehensive care plan will be created/maintained; patient will receive a copy]
• [Cost-sharing: CCM may result in coinsurance or deductible charges on patient statements]
• [One-practitioner rule: only one practitioner may bill CCM per calendar month; patient confirmed not enrolled elsewhere]
• [Right to stop: patient may discontinue CCM at any time by notifying the office, effective at end of calendar month]
• [Patient questions addressed; teach-back confirmed understanding] (Optional; include if performed.)

Consent Decision

Decision: [Accepted / Declined]

Consent Type: [Verbal / Written]

Date/Time of Consent: [Date and time]

Consenting Party: [Patient] or [Surrogate: name, relationship, legal authority]

Attestation: [Consenting party was informed of CCM services, potential cost-sharing, the one-practitioner-per-month rule, 24/7 access, care plan availability, and the right to stop at any time effective end of calendar month. Consenting party provided verbal/written consent to enroll in CCM.] (Adjust language to reflect acceptance or declination.)

(If written consent:) Written Consent Form: [Storage location]; Copy Provided: [yes / no]

(If declined:) Declination: [Reason if offered]; education was provided and the offer remains open for future consideration. (Omit Care Plan Status section if declined.)

Care Plan Status

(Include only if consent accepted; omit entirely if declined.)

Status: [Created today / Reviewed and updated today / Will be created by date]

Key Problems Addressed: [Active problems targeted by CCM]

Patient-Centered Goals: [One to three goals, stated in patient's terms when possible]

Immediate Next Steps: [Medication reconciliation, referrals, labs, home monitoring coordination, care coordination with specialists or community resources as applicable]

Care Plan Copy: [Provided to patient/caregiver via portal / printed / mailed] or [Pending; will be provided by date]

Next Steps

• [Expected first CCM outreach timeframe]
• [Scheduled appointments or planned follow-ups]
• [Escalation instructions: emergencies call 911; urgent concerns contact care team via 24/7 method]

Signature

Author: [Name, credentials] | Date: [Date] | Time: [Time]