PCMH Consent Form

AuthorizationandConsentfor Participationin thePCPCHPatientCenteredPrimary CareHomeProgram

Iunderstand that in signing thisAuthorizationand Consent for Participation in the PCPCH Patient Centered Primary Care Home Program(“PCPCH program”) thatIam agreeingtoparticipate with myprimary care provider (PCP) in a comprehensive approach tomedical care.The PCPCH program is intended topromoteinformation sharing between patients and their PCPcare teamsothat everyonehasa completepicture of existingand potential health risks for the purpose of producing better health outcomes.The PCPCH program encourages healthcare team partnershipswith the patient and care team toenhance overall care.These partnerships mayinclude my PCP, otherphysicians/practitioners, specialists towhom Iam referredfor care or from whom I receivecare, and other healthcare professionalsinvolvedin the treatment or prevention of medical conditions.

Byparticipating inthisPCPCHprogram, my PCPandthe care team have agreedtoprovide:

Comprehensive, coordinated care,

Quality andsafety using evidence-based practices, and

Team basedcare toinclude provider leadership, an interdisciplinary careteam, and effective staff communications.

Byparticipating inthisPCMHprogram, the patient(parent/guardian)agrees to:

Ask questions, share your thoughts and be involvedin your care,

Work with your care teamtoestablish and follow a care plan,

Keep appointments and communicate in advanceif you are not able tomake an appointment, and

Commit towork in conjunction with your established care team.

Ifindicated below, boththe care teamand patient agree toparticipate in the PCPCH program, as defined, throughoutthe duration of the program.Additionally, thisagreement may be terminatedby either party at any time due todissatisfactionor otherreasons.A copy of this Authorization and Consent will be placed inmy medical record, and a copy will be providedto me upon request.ThisAuthorization and Consent extends to information placed in my medical fileafter theeffective date of thisAuthorization and Consent. I understand I may revokemy decisiontoparticipate in the PCPCH Program at any timethrough a written request tomy care team.

Checkone:PatientAgreestoPCPCH ProgramPatientDeclines PCPCH Program

Patient Name(printed):

Date:

Patient Signature:

Parent/Guardian Signature:

For OfficeUseOnly:

□Enteredinelectronicrecord

□Pt declines –notificationsent

□Verbal agreement/declination received

(date/initials):

Updated6/2012