Confirmation of Your Primary Care Physician
Please complete the below form to select your primary care physician.
Medicare has started an initiative where health care providers who share a common set of goals aimed at improving patient care can work together more effectively. This initiative brings together health care professionals in a Direct Contracting Entity (DCE), to work together with Medicare to give you more coordinated care and services.
__________ is voluntarily taking part in this new initiative by joining 360 Health Primary Providers DCE because we think it will help us provide better quality care for our patients.
You are receiving this letter and form because your doctor or other health care professional thinks that you might benefit from care coordination and preventive services offered by 360 Health Primary Providers DCE.
These services include:
- Home Visits: Medicare may allow us to send a nurse or other healthcare provider to your home to help you manage your healthcare needs, even if you are not homebound. We can also send nurses and other staff to your home up to nine times after you are discharged from a hospital to help you follow the discharge plan your doctor writes.
- Reduced or Eliminated Out-of-Pocket Expenses: Medicare allows us to reduce or eliminate your costs for some Medicare Part B services and provide rewards for participating in chronic care management programs.
- Skilled Nursing Facilities: If your doctor thinks you need skilled therapy services, you may be able to go directly to a skilled nursing facility for therapy instead of having a 3-day hospital stay first.
You can use this form to confirm that __________ is the main doctor or other health care professional you see or the main place you go for routine care, to help determine if 360 Health Primary Providers DCE should help coordinate your care. Routine care can include regular care and check-ups you get from a doctor or other health care professional and care for other chronic health problems, such as asthma, diabetes, and hypertension.
Alternatively, instead of returning this form, you can also log into MyMedicare.gov and select your main doctor or other health care professional in order to determine whether __________ should help with coordinating your care. Instructions for navigating MyMedicare.gov are included with this letter. If you make a selection on this form and make a different selection through MyMedicare.gov, Medicare will prioritize the selection you make through MyMedicare.gov.
Your benefits will NOT change, and you can visit any doctor, other health care professional, or hospital. Whether or not you complete this form or select a doctor or other health care professional through MyMedicare.gov, you remain eligible to receive the same Medicare benefits and you still have the right to use any doctor, other health care professional, or hospital that accepts Medicare, at any time. If you have questions, feel free to ask your doctor or other health care professional, call 360 Health Primary Providers DCE at (800) 253-9999, or call Medicare at 1-800-MEDICARE (1-800-633-4227) to ask about DCEs. TTY users should call 1-877-486-2048.
Completing this form or selecting a doctor or other health care professional through MyMedicare.gov is your choice AND you can change your mind. If you choose to complete this form or select a doctor or other health care professional through MyMedicare.gov you should do so yourself. No one else should complete this for you.
No one is allowed to attempt to influence your choice to complete this form or select a doctor or other health care professional through MyMedicare.gov by offering or withholding anything in exchange for you to complete or not complete the form or to make a selection online. If you feel pressured to sign or not sign this form or to make a selection online, please call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
Please call 1-800-253-9999 or update your online selection if you change your mind later about whether you consider __________ to be the main doctor or other health care professional you see or the main place you go for routine care.
Get more information about DCEs.
Confirm and Submit
By signing below I am confirming that my main doctor or other healthcare professional – or the main place I go to for routine medical care – is __________.
Signature Verification Statement
- I consent to signing this Form electronically.
- I agree that my electronic signature is the legal equivalent of my handwritten signature on this Form and further that my signature on this document is as valid as if I signed the document in writing.
- I agree that no certification authority or verification is necessary to validate this signature and that this is a legally binding document between me and __________.
- I am confirming that I am a Medicare beneficiary authorized to complete this Form.