ADC Existing Patient Forms 

ADC  New Patient Form

The ADC Chronic Care Management program manager Crystal Chandler has compiled a list of questions that may help you decide whether CCM is a good fit for you.

Q: What is the Chronic Care Management program?

A: As we get older there is an increase in the number of medications that we take and the amount of medical conditions that we have which puts us at higher risk of getting ill. The CCM program is designed to reduce complications and hospitalizations that are more frequent for patients with multiple medical issues. You typically only see your primary doctor in the office 2 or 3 times per year which makes it hard to monitor your health status between office visits. With the CCM program, you will have a care coordinator from your doctor’s office who will contact you every month to review your health needs. They will work with you to create a plan of care and to set goals that will lead to better health. This enhanced communication between you and your healthcare team will help to improve the quality of your medical care.

Q: Who qualifies for the CCM program?

A: Any patient with 2 or more chronic conditions

Q: How can the CCM program benefit you?

A: CCM services include

  • Contact from physician or clinical staff between office visits to assess your health care needs, answer any questions, and educate you and/or your caregiver
  • Detailed reviewing and updating of your medication list on a regular basis
  • Development of a personal plan of care with achievable goals
  • Reminders about preventive services that are needed
  • Access to care 24 hours a day, 7 days a week
  • Prompt follow up after you are discharged from the hospital
  • Coordination of care with your specialists, home health, or others who are involved in your healthcare

Q: What do you need to do to enroll?

A: Discuss with your physician at an office visit and sign the CCM Patient Consent form. Only one physician can provide these services for you each month.

Q: Will you have to pay anything to be enrolled in the CCM program?

A: Your insurance only covers 80% so you will pay a co-pay of around $8-9 per month for this service. If you have supplemental insurance, your co-pay may be covered by them. Please keep in mind that the goal of this program is to prevent unnecessary complications or hospitalizations which can be very costly to you. We hope that the long-term benefits provided to you by the CCM program will more than make up for the monthly charge.

Q: Can you stop CCM services at any time?

A: Yes, you can revoke services at any time by contacting your physician’s office. This revocation will take effect at the end of the current calendar month.

Q: What else do you need to know?

A: We know life is busy and taking care of your health is not always easy. With this program we will make you a priority and help you stay on top of everything with important reminders and suggestions. We are available to assist you any time you need us and will work together to improve your overall health.

You may contact the CCM program manager, at (512) 901-4468 with any questions.

Who Pays for Chronic Care Management (CCM) services?

  • Chronic Care Management (CCM) services are an insurance benefit and will be covered 80% by Medicare and other insurances. The remaining 20% will be the patient’s responsibility which equals around $8 per month.
  • Sometimes, supplemental insurance in addition to Medicare may cover some or all of the $8 per month copay. You will need to check with your individual insurance for coverage questions.
  • A bill will be submitted to Medicare only when billable services have been provided and may be as often as every month.
  • Please remember that only one physician can bill for this service per month. This physician will oversee your chronic care needs and work in conjunction with your other healthcare providers.
  • Medicare, in some instances, does not allow CCM services to be billed for when specific other services have been provided in a given month.
  • You can opt out of CCM services at any time by notifying the physician’s office that you signed up with for this service.
  • You will receive a bill from The Austin Diagnostic Clinic (ADC) if any amount is due that has not been covered by Medicare or other insurance.

Download: Who pays for chronic care management? (PDF)

Chronic Care Management (CCM) patient forms:

Endocrinology is a specialty that focuses on treating patients with hormonal disorders.  Although diabetes and thyroid disease are the most common, we also care for patients with growth, pituitary, adrenal, gonadal, bone and lipid disorders.  We would like to welcome you to the section.

We have compiled a list of helpful information including:

  • Providers
  • Locations
  • Services
  • Office Procedures
  • Helpful numbers

You may download the Endocrinology Department Information (PDF):

ADC Endcorinology Patient Information

The Medicare Health Assessment Review will be used by your provider during your Annual Wellness Medicare visit.   Please print, complete and bring the review to your visit.

These Annual Wellness Medicare visit provides a routine evaluation if you are healthy or have stable medical conditions. The treatment of other medical concerns, new or existing, are not included in these visits. You must schedule a separate appointment to address those concerns and be covered by your Medicare benefits.

Save some time at your doctor’s office.  Complete and print the form below before your visit.  Remember to bring it to your appointment.

The following doctors have provided forms for you to complete at home.  Print, complete and bring to your visit.

Welcome to the ADC Weight and Risk Management program.  Please print, complete and bring these forms to your first visit.

Welcome to the Women’s Imaging Center.  So that you may relax before your appointment, we’ve posted these forms to print and complete at home.  Remember to bring them to your mammogram visit.

Your doctor may ask you to use or bring these forms to your visit.

PreNatal Visit Forms

Save time and complete your patient form ahead of time. Just print the form below, complete and bring to your visit.


The Advance Beneficiary Notice of Noncoverage (ABN) is a notice given to beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a specific case.

“Notifiers” include physicians, providers (including institutional providers like outpatient hospitals), practitioners and suppliers paid under Part B (including independent laboratories), as well as hospice providers and religious non-medical health care institutions (RNHCIs) paid exclusively under Part A.

They must complete the ABN as described below, and deliver the notice to affected beneficiaries or their representative before providing the items or services that are the subject of the notice. (Note that although Medicare inpatient hospitals and home health agencies (HHAs) use other approved notices for this purpose, skilled nursing facilities (SNFs) must use the revised ABN for Part B items and services.) Beginning March 1, 2009, the ABN-G and ABN-L will no longer be valid; and notifiers must begin using the revised Advance Beneficiary Notice of Noncoverage (CMS-R-131).

The ABN must be verbally reviewed with the beneficiary or his/her representative and any questions raised during that review must be answered before it is signed. The ABN must be delivered far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice.

Employees or subcontractors of the notifier may deliver the ABN. ABNs are never required in emergency or urgent care situations. Once all blanks are completed and the form is signed, a copy is given to the beneficiary or representative. In all cases, the notifier must retain the original notice on file.

Save time at the doctor’s office.  Print, complete and bring your form to your visit.

Take the time to print and complete your patient paperwork before your visit.

Make the most of your visit.  Print, complete and bring your forms to your visit.


Make your appointment faster!

Fill these forms out ahead of your appointment and bring them with you. It will save you time and help us get you into your appointment sooner.

Make the most of your time at your appointment.  Find your doctor, print and complete the forms below before your visit. Remember to bring the completed form to your doctor’s office.

Dr. Cepeda’s forms

Dr. Harper’s forms

Dr. Osgood’s form

Dr. Parker’s forms

Dr. Tew’s form

Forms to make your visit easier.

  • New patient form (pdf) – Fill this form out ahead of your appointment and bring it with you. It will save you time and help us get you into your appointment sooner.
  • Endocrinology Department Information (pdf) – important numbers, office procedures, and more

Make your appointment faster!

Fill this form out ahead of your appointment and bring it with you. It will save you time and help us get you into your appointment sooner.

Prepare ahead of time – print and complete the form below before your visit.  Remember to bring it to your appointment.

Be prepared for your appointment.

Save time before your appointment! Print and complete this form and bring it to your visit.

Be prepared for your appointment.

Make your appointment faster! Print these forms and bring them with you.

Visits involving the forms below require special scheduling.
Parents shoud contact the office before your visit to let us know you want to discuss possible ADD.

Be prepared for your appointment.

Complete this form, print and bring them with you to your visit.  A completed form is required for each traveler.

A woman reaches menopause when she has gone 12 months in a row without a period. You can keep track of your menstrual cycle using this menstrual calendar from The North American Menopause Society (NAMS).