ACO Logo [POSTER] [Our Practice] [Doctor s name] is participating in a Medicare Shared Savings Accountable Care Organization

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1 [POSTER] [Our Practice] [Doctor s name] is participating in a Medicare Shared Savings Accountable Care Organization [Name of Doctor] [Name of Practice] Is Participating in a New Care Coordination Program in Medicare What s An Accountable Care Organization (ACO)? ACOs are groups of doctors and other health care providers who voluntarily work together with Medicare to give you high quality service and care at the right time in the right setting. Your doctor has agreed to participate in a Medicare Shared Savings ACO and to work closely with other doctors and health care providers in the ACO to coordinate care for Medicare beneficiaries, like yourself, who have traditional Medicare. The ACO may share in any savings that result from providing you with high quality and more coordinated care. ACOs Don t Change Your Medicare Benefits An ACO is not a Medicare Advantage plan or an HMO plan. If you have traditional Medicare, you still have the right to use any doctor or hospital who accepts Medicare, at any time. [Doctor s name] [Practice Name] may continue to recommend that you see particular doctors for your specific health needs, but it s always your choice about what doctors you use or hospitals you visit. How Will An ACO Help My Doctor Coordinate My Care? You benefit because your doctors will be part of a better coordinated team. You may not have to fill out as many medical forms that ask for the same information. Each of your doctors will not only know about the health issues they ve treated, they will have a more complete picture of your health through talking with your other doctors. Questions If you have questions or concerns, you can talk with [Doctor s name] [Practice Name] at anytime. You can also visit or call MEDICARE (TTY users should call ).

2 NOTICE TO PATIENTS: [Name of Doctor/Practice] is participating in an Accountable Care Organization and Information on sharing your health information <BENEFICIARY FULL NAME> <ADDRESS> <CITY STATE ZIP> <file creation date> [Name of Doctor] Is Participating in a New Care Coordination Program This letter is to let you know that I, Dr. XXX [and my practice] have chosen to participate in a Medicare Accountable Care Organization (ACO). We re Working to Improve Your Care An ACO is a group of doctors and other health care providers working together with Medicare to give you better service and care. The goal of an ACO is for your doctors to communicate closely with your other health care providers to deliver high-quality care and meet your unique individual needs and preferences. The ACO may be rewarded for providing you with high quality, more coordinated care. You Can Still See Any Doctor or go to any Hospital Your Medicare benefits are not changing, and you will still receive your benefits through Original Medicare. This isn t a Medicare Advantage plan or an HMO plan. You still have the right to use any doctor or hospital who accepts Medicare, at any time. [I/we] may continue to recommend that you see particular doctors for your specific health needs, but it s always your choice about what doctors you use or hospitals you visit. You Control Your Personal Information To help us give you the right care in the right place at the right time, on [insert date 30 days after the date of this notice], Medicare plans to start sharing certain health information with us about your care. This information will include things like visits to the doctor or hospital, medical conditions, and prescriptions you ve had in the past and moving forward. Having this information will help [me/us] and your other health care providers participating in our ACO give you high-quality care, because [I ll/we ll] have the most up-to-date information about your health. Page 1 of 2

3 Your privacy is very important to us, and you control the use of your personal health information. Like Medicare, we have important safeguards in place to make sure all your medical information is safe. You Can Choose to Not Share Your Health Information If you choose, you can ask Medicare not to share your personal health information with us by doing one of these things: Call MEDICARE ( ). TTY users should call Complete and Sign the Declining to Share Personal Health Information form in [our] [your doctor s] office. Complete, sign, and return the Declining to Share Personal Health Information form included with this letter. If you want to ask Medicare not to share your information with us, you should take one of the three steps described above by [insert a date 30 days after the date of this notice]. Even after Medicare begins to share your information with us, you may always ask Medicare to stop this information-sharing in the future. Please note, however, that Medicare will not share any information about alcohol or drug treatment without express written permission. If you have received such treatment, it is important that we understand all of your health needs in order to allow the health care providers that treat you to coordinate your care. To give this permission, complete the Consent for the Release of Confidential Alcohol or Drug Treatment Information form and give it to [me/us] or mail it to the address indicated on the form. If you have received such treatment, consenting to allow Medicare to share this information about you with us will not change who you go to for alcohol or drug abuse prevention, treatment or recovery supports, but will help us provide better health care for you. You may withdraw your consent to share this information at any time either in writing or over the phone if you want Medicare to stop sharing this information. Questions If you have questions or concerns, you can call us at [phone number], or bring it up next time you re in your doctor s office. You can also visit or call MEDICARE and tell the operator you are asking about ACOs (TTY users should call ). Page 2 of 2

4 Date: Declining to Share Personal Health Information Please sign this form if you do NOT want Medicare to share your personal health information with [Name of ACO]. You can also call MEDICARE ( ) instead of completing this form. TTY users should call Your decision not to share your personal health information with [Name of ACO] will remain in effect until you tell us that you have changed your preference. You may change your decision not to share your personal information at any time. See the different ways you can submit your preferences on page 2 of this form. Your request will take effect in approximately 45 business days. Your Information Name (First and last name of the person with Medicare): Physical Street Address: City: State: Zip Code: Mailing Address (if different): City: State: Zip Code: Instructions for Declining to Share Personal Health Information No, please do not allow Medicare to share any of my personal health information with [Name of ACO]. Signature of Patient Print Name Date: 1 of 2

5 2 of 2 ACO Check here if the person completing and signing this document is serving in the capacity of a personal representative of the listed Medicare beneficiary. Please attach the appropriate documentation to demonstrate your legal authority to execute this document on behalf of the beneficiary (for example, Durable Medical Power of Attorney). This box should only be checked if someone other than the Medicare beneficiary signed above. Print the Personal Representative s Address (Street Address, City, State, and ZIP): Telephone Number of Personal Representative: Personal Representative's Relationship to the Beneficiary: How to Submit Your Preference Fill out, sign and return this form to your provider s office in person, or via mail to the following address by [date]: OR [ACO Name ACO Address Line 1 ACO Address Line 2 City, State ZIP] Call MEDICARE at and say that you wish Medicare to stop sharing your personal information with [Name of ACO], or that you want to talk about ACOs. Questions If you have any questions, please contact MEDICARE at and tell the operator you are asking about ACOs. TTY users should call

6 Date: Consent for the Release of Confidential Alcohol or Drug Treatment Information If you have received such treatment, Medicare will only share information relating to your alcohol or drug abuse diagnosis, treatment, or referral for treatment with your doctor s Accountable Care Organization (ACO) with your written consent. Please sign this form if you wish to allow Medicare to share information about your alcohol or drug diagnosis, treatment or referral for treatment with [Name of ACO] that your doctor participates in. Your decision to allow Medicare to share this information will remain in effect unless you change your preference. You may choose to withdraw your consent to share your alcohol or drug treatment information at any time. Your requested change will take place within 45 business days after your notification. Your Information Name (First and last name of the person with Medicare): Physical Street Address: City: State: Zip Code: Mailing Address (if different): City: State: Zip Code: 1 of 3

7 Consent for Release I,, authorize Medicare to disclose to [Name of ACO] (Name of patient) all information regarding my past, present, and future treatment for alcohol, drug treatment, or substance abuse. The purpose of the disclosure of these records is to give my doctors and other health care providers involved in my care accurate and timely information about my medical history to allow the health care providers that treat me to coordinate my care. I understand that my records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may withdraw my consent at any time and my preference will be honored within 45 days of my request. If I do not change my preference to share this information, I understand that my information will continue to be shared with the ACO until their program participation ends.. Signature of Patient Print Name Date: Check here if the person completing and signing this document is serving in the capacity of a personal representative of the listed Medicare beneficiary. Please attach the appropriate documentation to demonstrate your legal authority to execute this document on behalf of the beneficiary (for example, Durable Medical Power of Attorney). This box should only be checked if someone other than the Medicare beneficiary signed above. Print the Personal Representative s Address (Street Address, City, State, and ZIP): Telephone Number of Personal Representative: Personal Representative's Relationship to the Beneficiary: 2 of 3

8 How to Submit Your Form To submit your consent to share information about your alcohol or drug diagnosis, treatment or referral for treatment with [Name of ACO], please fill out, sign and return this form to your doctor s office in person, or via mail to the following address : [ACO Name ACO Address Line 1 ACO Address Line 2 City, State ZIP] Questions If you have any questions, please contact MEDICARE and tell the operator you are asking about ACOs at TTY users should call of 3