Section I: Case Management Consent

I agree to participate in the case management program administered by Excellus BlueCross BlueShield or its contracted agency (Health Plan) for the condition(s) initialed below. This is a collaborative process between myself, my Health Plan care manager and my health care team. Case Management services may include general health education, coordination of care with my health care team, and referrals to appropriate community resources. By agreeing to participate and by signing below:

I consent to and agree that I can be contacted by telephone at the number(s) provided, in writing, or in person by the Health Plan care manager(s) for case management of my health condition(s).
I understand that:
- The case management program is voluntary, except where otherwise required under my contract benefits, and when voluntary, I may withdraw from the program at any time by notifying the Health Plan either verbally or in writing.
- This consent to case management is not a condition for receiving care or treatment by my physician or coverage by the health plan, except where otherwise required under my contract benefits.
- This consent is to remain in effect as long as I remain in the case management program. I can revoke this consent at any time by notifying the Health Plan either verbally or in writing (when required) except this revocation would not affect any action taken by the Health Plan in reliance on this consent before my revocation is received.
- I will follow the contractual provisions of my health insurance contract and the case management program policies and guidelines of the Health Plan.
- As permissible under state and federal laws, the Health Plan may use my personal health information (PHI) in its possession to help provide case management resources and services to me.
- Any information I share as part of the Health Plan’s case management program can be shared with any other entity that is involved in and helps manage my care.
If the case management program I am receiving includes the ability to have in-person meetings, I understand that agreeing to any in-person meeting in a public place (such as a coffee shop, library or shared household), means there are risks associated. This means that some people may overhear us talking about my health information.

THIS WEBSITE USES COOKIES