Medical Records Release Authorization
Pain Medication Agreement

Current Physician Office Locations

Flagstaff, AZ La Palma, CA Redwood City, CA Boulder, CO Boynton Beach, FL Atlanta, GA

Marietta, GA Kahului, HI Kilauea, HI Warrenville, IL Beltsville, MD Lynbrook, NY

West Hempstead, NY Iselin, NJ Las Vegas, NV Downingtown, PA Knoxville, TN Richmond, VA

In order for Chronic Care Consultants to coordinate your medical services, we will be required to collect and use protected health information as regulated by HIPAA. Chronic Care Consultants will keep confidential and protect your health care information to the same extent as would a covered entity under the HIPAA disclosures http://www.hhs.gov/ocr/privacysummary.pdf. In order to use the services of Chronic Care Consultants, you will be required to submit a signed HIPAA release form and copy of government-issued identification. You will authorize the representatives of Chronic Care Consultants to contact your health care providers and use your health care information for the purpose of providing information to your health care providers.

FAQ
How do I apply to be a Chronic Care Consultants patient?
First, call or go online to register and provide us with basic information about yourself, your general health, and any medications you are currently taking. You will be given payment options to select from and once your account is verified you may request an appointment for a face-to-face consultation with a doctor closest to where you live. Before you can receive a consultation we will require a faxed copy of your valid government-issued photo identification, signed HIPAA release, and medical records. Your records should refer to the condition that you wish to discuss with the doctor and should be as comprehensive as possible. You must be at least 21 years old to be a Chronic Care Consultants patient.

What is required of my medical records?
You must submit medical records that provide clear documentation of your current medical status, and that justify the need for ongoing treatment of your chronic condition. Your records must show evidence of a positive diagnosis of your condition as well as your past treatment plan(s). If you already possess a copy of your medical records, you may fax them directly to us, or we can retrieve your records from your providers' office with your HIPAA release. If you submit your records, we will need to contact your medical provider to verify the accuracy of your records. If we retrieve your records, the verification process will not be necessary, however the retrieval might take longer regardless. Any reasonable copying fees charged by your providers' office will be passed on to you. The medical records collection process must be complete before any consultation can be scheduled.

How does the consultation work?
Chronic Care Consultants will coordinate your appointment with the physician. You will be required to attend the doctor’s offices at the appointed time. Please allow plenty of traveling time and aim to arrive 15 minutes before your appointment. Once the consultation is complete the physician will provide you with a plan of care. Only properly licensed and credentialed physicians are referred, with physician coordination services provided by Chronic Care Consultants, Inc. Chronic Care Consultants is not a physician practice, and does not control the medical decisions made by the consulting practitioners. It is up to your consulting physician to make decisions about your qualifications for participation in the program and your treatment plan. Consulting physicians will not prescribe Schedule II controlled substances. The physicians do follow a published set of common guidelines relating to Chronic Care Consultants' services as well as following the proper standard of care required by their licensure and profession.

How are prescriptions handled?
Prescriptions are provided to you in a manner determined by your consulting physician. They may be called or faxed in to the pharmacy of your choice, or the physician may give you the prescription to be filled in a manner of your choosing. Chronic Care Consultants does not provide pharmacy services, and does not deliver, distribute, or dispense medication of any kind including controlled substances. In the course of providing therapy for treatment of referred patients' chronic conditions, Chronic Care Consultants physicians may prescribe controlled substances. While it would appear that the provisions of the Controlled Substances Act (21 U.S.C. 831(a)) do not apply to Chronic Care Consultants, the following information is posted to ensure compliance if necessary: Practitioner Information This online pharmacy will only dispense a controlled substance to a person who has a valid prescription issued for a legitimate medical purpose based upon a medical relationship with a prescribing practitioner. This includes at least one prior in-person medical evaluation or medical evaluation via telemedicine in accordance with applicable requirements of section 309.

What are the charges for Chronic Care Consultants services, and what payment methods are available?
The current charge for in-person examinations is $299, and phone follow-up consultations are $159. Consultation prices include costs for administration and coordination services, which may vary. If you apply to become a Chronic Care Consultants patient, but do not qualify based on your medical records before you have consulted with a doctor, your consultation fees will be refunded to you minus $50 for medical records processing. If it is determined that you do not qualify for treatment by Chronic Care Consultants after you have already consulted with a physician, your charge will be $200. You may pay by credit card or money order. Your patient support representative can give you instructions on submitting a money order payment, which must be received before services can be provided.

Is my information safe and private?
Of course. We ensure the security and privacy of your protected health information and we do not disclose any details to any third party. You and your doctor will establish and maintain a valid physician/patient relationship and both Chronic Care Consultants and your doctor will keep your medical history information in a patient file in a secure place. All online transactions are encrypted using industry standard technology, and all personal and credit card information (where applicable) is submitted with the highest level of security and care. Our systems also include safeguards to protect against credit card fraud. Individuals attempting the fraudulent use of a credit card or money order will be reported to the appropriate authorities.