Confirmation of Main Doctor

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Confirmation of Main Doctor or Other Healthcare Professional Form
- Dear Medicare Beneficiary:
  
  Please complete this form to confirm our practice is the main place you go for routine care.
  
  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 an Accountable Care Organization (ACO), to work together with Medicare to give you more coordinated care and services.
  
  Our practice is voluntarily taking part in this new initiative by joining {dce_name} 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 {dce_name}.
  
  You can use this form to confirm that our practice is the main doctor or other health care professional you see or the main place you go for routine care, to help determine if {dce_name} 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.
  
  Please return your completed form as soon as possible.
  
  Alternatively, instead of returning this form, you can also log into Medicare.gov and select your main doctor or other health care professional in order to determine whether {dce_name} 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.
  
  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 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 {dce_name} at {dce_phone}, or call Medicare at 1-800-MEDICARE (1-800-633-4227) to ask about ACOs. TTY users should call 1-877-486-2048.
  
  Completing this form or selecting a doctor or other health care professional through Medicare.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 Medicare.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 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.
  
  Please call {dce_phone} or update your online selection if you change your mind later about whether you consider our practice 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 ACOs:
  
  CMS Website: https://innovation.cms.gov/innovation-models/gpdc-model
  
  ACO Website: {dce_url}
- 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:
- Provider Name and/or Medical Group
- Beneficiary First Name
- Beneficiary Last Name
- Beneficiary Name
- Medicare Number
- Signature
- Date
  
  MonthDayYear
- Signer's Name
- DCE Name
- DCE Phone
- 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 {dce_name} at {dce_phone}.
  
  Note: Completing and returning this form is voluntary. It won't affect your Medicare benefits.
  
  {dce_form_ycode}
- YCode
- Internal Code
- Letter ID Prefix
- Letter ID
- Network Number
  ERROR. Please load this form using the unique URL given to you (e.g. yesdoc.us/ABCD1234)
- Language
- DCE URL
- Practice ID
- Error: Wrong URL
  
  You have accessed this form using an incorrect URL. Please load this form using the unique URL given to you (e.g. yesdoc.us/ABCD1234).
- DCE Form Redirect
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Confirmation of Main Doctor or Other Healthcare Professional Form

Dear Medicare Beneficiary:

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