Consent Agreement for Provision of Advanced Primary Care Management and Chronic Care Management Services

By signing this Agreement, you consent to Bloom Healthcare (referred to as "Provider"), providing Advanced Primary Care Management services (referred to as "APCM Services") and Chronic Care Management Services (referred to as "CCM Services") to you as more fully described below.

APCM and CCM Services are available to you because you have been diagnosed with two (2) or more chronic conditions which are expected to last at least twelve (12) months and which place you at significant risk of further decline.

Both APCM and CCM Services include 24-hours-a-day, 7-days-a-week access to a health care provider in Provider's practice to address acute chronic care needs; systematic assessment of your health care needs; processes to assure that you timely receive preventative care services; medication reviews and oversight; a plan of care covering your health issues; and management of care transitions among health care providers and settings. The Provider will discuss with you the specific services that will be available to you and how to access those services.

Provider's Obligations When providing APCM or CCM Services, the Provider must:

• Explain to you (and your caregiver, if applicable) and offer to you, all the services that are applicable to your conditions
• Provide to you written or electronic copy of your care plan upon request.
• If you revoke this Agreement, provide you with a written confirmation of the revocation, stating the effective date of the revocation.

Beneficiary Acknowledgment and Authorization By signing this Agreement, you agree to the following:

• You consent to the Provider providing APCM or CCM Services; your Provider will determine which service is most beneficial to your care based on your health needs.
• You authorize electronic communication of your medical information with other treating providers as part of coordination of your care.
• You acknowledge that only one practitioner can furnish APCM or CCM Services to you during a calendar month.
• You understand that cost-sharing may apply to APCM and CCM Services, so you may be billed for a portion of APCM or CCM Services even though APCM or CCM Services will not involve a face-to-face meeting with the Provider.

Beneficiary Rights You have the following rights with respect to APCM and CCM Services:

• The Provider will provide you with a written or electronic copy of your care plan.
• You have the right to stop APCM or CCM Services at any time by revoking this Agreement effective at the end of the then-current month. Upon receipt of your revocation, the Provider will give you written confirmation (including the effective date) of revocation. You may revoke this agreement verbally or in writing to Bloom Healthcare: