Consent to Enroll in Case Management Form

Please read this statement carefully:

CBA Case Management Consent

  • I have read and understand the description of case management and agree to participate in case management services.
  • I have read and I understand my patient rights under case management as outlined in the CBA case management brochure.
  • I understand that my participation in case management is strictly voluntary and that I may request that services be terminated at any time.
  • I understand that insurance benefits used during case management will continue to be subject to my eligibility at the time services are rendered.
  • I understand that case management requires my participation and that my case manager will work closely with me and my health care providers in order to coordinate the most effective services.

By entering my initials and submitting this form, I authorize my case manager to initiate case management services upon receipt of this consent form.

Please type your full name in the signature box if you are 16 years of age or older. For members younger than 16 years of age, a parent or legal guardian must sign this form.

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