AGREEMENT TO RECEIVE MEDICARE ADVANCED PRIMARY CARE MANAGEMENT (APCM) SERVICES

Medicare covers Advanced Primary Care Management (APCM) services provided monthly by physician practices. I understand that my primary care physician is assuming responsibility for all my primary care services and will be a continuing focal point for all my needed health care. In agreeing to receive APCM, I understand that my physician and the Rivers Family Medicine care team are willing to provide such services to me.

I also understand that I can revoke this agreement at any time (effective at the end of a calendar month) and can choose, instead, to receive these services from another health care professional after the calendar month in which I revoke this agreement. Medicare will only pay one physician or health care professional to furnish me with APCM services within a given calendar month.

I understand these APCM services are subject to the usual Medicare deductible and coinsurance applied to physician services.

My signature authorizes my primary care physician to electronically communicate my medical information with other treating providers as part of the care coordination involved in APCM.

This designation is effective as of the date below and remains in effect until revoked by me.