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Our practice wishes to enhance patient care by offering MEDICARE's Chronic Care Management Services. Patients need to sign up so please read and sign the following and mail back to our office at:

595 Chestnut Ridge Road, Suite 6
Woodcliff Lake, NJ 07677

Click HERE to download and print a consent form to fill out. 

Essentially by signing this Agreement, you consent to Dr. Alexander Biener providing MEDICARE’s chronic care management services (CCM Services).   MEDICARE’s 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 or expensive hospitalizations.   MEDICARE is offering these home services to help prevent disability or expensive hospitalizations related to your chronic medical conditions.

MEDICARE’s 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 preventive care services; medication reviews and oversight; a plan of care covering your health issues, and management of care transitions among your health care providers and or facilities you may need. Dr.Biener will discuss with you the specific services that will be available to you hand how to access those services.

Provider’s Obligations

When providing CCM Services, the Provider must:

  • Explain to you (and your caregiver, if applicable), and offer to you, all the CCM Services that are applicable to your condition.
  • Provide you a written copy of your care plan. 

Beneficiary Acknowledgement and Authorization

By signing this Agreement, you agree to the following:

  • You consent to the Provider providing CCM Services to you.
  • You authorize electronic communication of your medical information with other treating providers as part of coordination of care.
  • You acknowledge that only one practitioner can furnish CCM Services to you during a thirty (30)-day period.
  • You understand that cost-sharing will apply to CCM Services, so you may be billed for a portion of CCM Services (up to $8 per month) even though CCM Services will not involve a face-to-face meeting with the Provider, and will allow us to continue caring for you with less office visits.

Beneficiary Rights

You have the following rights with respect to CCM Services:

  • The Provider will provide you with a written copy of your care plan.
  • You have the right to stop CCM Services at any time by revoking this Agreement effective at the end of the then-current thirty (30)-day period of services. You may revoke this Agreement verbally by calling 201-505-9595 or in writing to 595 Chestnut Ridge Road, Suite 6, Woodcliff Lake, NJ 07677. Upon receipt of your revocation, the Provider will give you written confirmation (including the effective date) of revocation.

Beneficiary, or Beneficiary’s Representative and/or Caregiver (if applicable)



Print Name:___________________________________________________________________________