Patient Doctor Relationship

Patient Confirmation Form

Dear Beneficiary:

Please Sign This Form to Notify Medicare that your Main Healthcare Provider is the provider you list below.

Medicare has a program where health care providers who share a common set of goals aimed at improving patient care can work more effectively together. This initiative brings together health care professionals in a, Accountable Care Organization (ACO), to work together with Medicare to give you more coordinated care and services.
Your provider is voluntarily taking part in this new initiative by joining Pathways Health Partners ACO, in the Direct Contracting Model, because we believe it will help us provide better quality care for our patients.

Your doctor or other health care professional thinks that you might benefit from care coordination and preventive services offered by Pathways and our associated provider groups.
Pathways, in partnership with your provider, will work as your patient advocate by using an integrated approach, removing potential barriers, and increasing your access to healthcare resources.  The goal is to deliver care at the right time, in the right place by the right provider while empowering you to be actively involved in your healthcare decisions with the provider you choose.

Use the form below to confirm that your provider, is the main doctor or other health care professional you see or the main place you go for routine care, to help determine if Pathways 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 completing this form, you can also visit www.medicare.gov and select your main doctor or other health care professional to determine whether Pathways should help with coordinating your care. If you make a selection on this form and make a different selection through Medicare.gov, Medicare will prioritize the most recently submitted selection.
Complete the form with your information, check the box agreeing to use your electronic signature and then click the “submit” box.

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 www.medicare.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 Pathways Health Partners at 800-632-6228, 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 www.medicare.gov is your choice AND you can change your mind whenever you like. There is NO open enrollment period.

If you choose to complete this form or select a doctor or other health care professional through www.medicare.gov you should do so yourself. No one else should complete this form 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 www.medicare.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.

Confirm your doctor below. We’ll light the path.

Please fill in the information below about your primary doctor or other healthcare professional that you see for routine medical care. Submit the form and you are well on your way to more modern, more personalized care.

Voluntary Alignment Form

"*" indicates required fields

MM slash DD slash YYYY
Your Medicare ID
Address*
By checking this box, I agree to using an electronic signature for this form and I confirm it is an electronic representation of my signature for the purposes of this document.*

Note: If the names listed above and in the attached letter are incorrect do not sign this form. If you would like to receive a new form with a different doctor, other healthcare professional, or practice listed, please call Pathways Health Partners at (800) 632-6228 to request a new form.”

Note: Completing and returning this form is voluntary. It won’t affect your Medicare benefits.