New Patient Packet English

*All fields are required
New Patient Intake Forms
Date

MonthDayYear
Date
Patient Information
Name*

First NameLast Name
DOB (Date of Birth)*

MonthDayYear
Date
Street*
City*
State*
Zip*
Cell Phone*
Home Phone
Email
example@example.com
Sex*

MaleFemale
Age
SSN #*
Martial Status

SingleMarriedWidowedSeparatedDivorced
Ethnicity:
Employer
Occupation
Street
City
State
Zip
Employers Phone
Name of Spouse
Cell Phone
Insurance Information
Primary Insurance*
Phone
Member ID*
Group #
Name of Policy Holder
DOB

MonthDayYear
Date
Secondary Insurance
Phone
Member ID
Group #
Name of Policy Holder
DOB

MonthDayYear
Date
Contact Information
Preferred Method of Contact:

PhoneEmailMail
Best Time to Contact You

A.M.P.M.
Emergency Contact/ Permission to release info to:
Name 1.
Phone #
Relation
Emergency Contact/ Permission to release info to:
Name 2.
Relation
Relation
Reason for your visit

Wellness Exam/ProgramWeight loss ProgramMale Hormone Therapy
Other (explain)
Assignment of Insurance Benefits, Release of Protected Health Information, Consent for Treatment, Guaranty and Statement of Service. Ihereby assign and authorize payment made directly to Dia Health of all my covered health insurance benefits, including Medicare, Medi gap, Commercial all third party payors may not cover part, or all of the medical services rendered. I fully understand I am financially responsible for and agree to pay all charges not paid by my health insurance plans or payors, including deductibles and coinsurance regardless of reason given for non-payment. I agree to immediately forward all payments, explanation of benefits, and correspondence sent directly to me from any and all third party payors related to care rendered by Primary Care Providers of Texas and agree that failure to do so will make me responsible for the entire billed charges. My assignment of benefits covers Primary Care Providers for all services now rendered in the future until this assignment is revoked. This assignment of benefits supersedes any previous assignment or agreements made with my insurance company and their related companies or any other third party payor to pay me directly. A copy of this form shall be considered valid as the original.
Printed Name of Patient or Personal Representative*
Date*

MonthDayYear
Date
Signature of Patient or Personal Representative*

Clear
Date*

MonthDayYear
Date
Personal Medical History

Please select if you have ever been diagnosed with or are experiencing any of the following symptoms.
Eyes/Head

GlaucomaColor BlindnessCataractsAstigmatismHeadachesDizzinessRetinopathy
Cardiovascular

Heart AttackStrokeHeart DiseaseRapid/Irregular Heat BeatHeart MurmurAngina (chest pain)High Blood PressureHigh CholesterolPeripheral Vascualr
Dermatology

Skin Rach: Eczema, Psoriasis Acne/ RosaceaSkin CancerShinglesDry/Cracked SkinOther
ENT

Sinus InfectionsRinging in Ears: TinnitusChronic Ear InfectionsOther
Endocrine

HypothyroidismHyperthyroidismDiabetes Type I Type IIObesity
Respiratory

AsthmaCOPDChronic BronchitisEmphysemaTuberculosisCongestive Heart Failure
Musculoskeletal

OsteopeniaOsteoporosisOsteoarthritisRheumatoid ArthritisFibromyalgiaChronic lower back painCarpal tunnel syndromeFracturesOther
GI

Reflux (GERO)Chronic ConstipationIrritable Bowel SyndromeColon PolypsHemorrhoidsHepatitisStomach UlcersLiver problemsOther
Neuro

SeizuresEpilepsyLoss of consciousnessInsomniaSleep ApneaDepressionAnxietyOther
Comments
Hematology

AnemiaBleeding DisordersPrevios Blood TransfusionsHIV/AIDSOther
Genitourinary

Blood in urine, burningStress IncontinenceOver Active BladderUrinary Tract Infections (UTI)Kidney StonesKidney DiseaseSexually Transmitted DiseaseCancer
Genitourinary Male

Prostate Problems: BPHProstate CancerProstatectomyVasectomyBreast: Cyst, LumpsBenign Prostatic HyperplasiaOther
Genitourinary Female

Menses Related ProblemsTubal LigationHysterectomy Total/PartialPost-MenopausalContraceptive MethodBreast: Cyst, LumpsBreast or Cervical CancerOther
Menstrual History
Age of onset:
Cycle every ________ days
Regular Irregular
Last Menstrual Period
Family Medical History
Mother
Father
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Brother
Sister
Other
Wellness and Prevention History
Do you have an advanced directive?*

YesNo
If yes, who?
Do you use tobacco products?

YesNo
What Kind?
How often?
Do you drink alcoholic beverages?

YesNo
Occasional?

YesNo
Do you have any history of illicit/ prescription drug abuse? Explain:
Do you have any dietary restrictions?

YesNo
Explain
Do you exercise regularly?

YesNo
If yes, what type?
How often?
Are you currently employed?

YesNo
Occupation?
Education Level:
Do your religious beliefs prevent you from obtaining certain medical care?

YesNo
If yes, explain:
Are you able to perform all activities of daily living independently:

BathingGroomingDressingCookingOther
Wellness History
Please list the date of any of the following:
Electrocardiogram (ECG/EKG)
Colonoscopy
Endoscopy
Bone Density Scan
Male
Prostate exam
Female
Pap Smear
PSA lab level
Mammogram
Breast Exam
Professional Contacts
Please list any Specialist doctors that you may currently be seeing.
Cardiologist
Endocrinologist
Neurologist
Nephrologist (kidney)
Gastroenterologist
Orthopedic
Optometrist/ Ophthalmologist
Medications and Allergies
Patient Name
Date

MonthDayYear
Date
Pharmacy(ies)
Retail Pharmacy
Mail Order Pharmacy
Compound Pharmacy
List Medication:
Dose:
Unit:
Indication:
List Medication:
Dose:
Unit:
Indication:
List Medication:
Dose:
Unit:
Indication:
List Medication:
Dose:
Unit:
Indication:
List Medication:
Dose:
Unit:
Indication:
List Medication:
Dose:
Unit:
Indication:
List Medication:
Dose:
Unit:
Indication:
List Medication:
Dose:
Unit:
Indication:
List Medication:
Dose:
Unit:
Indication:
List Medication:
Dose:
Unit:
Indication:
List All Medication(s), Dose, Unit, and Indication:
Surgeries
Procedure
Date

MonthDayYear
Date
Procedure
Date

MonthDayYear
Date
Procedure
Date

MonthDayYear
Date
Procedure
Date

MonthDayYear
Date
Procedure
Date

MonthDayYear
Date
Procedure
Date

MonthDayYear
Date
Allergies
Please list any allergy and symptom it caused.
Environmental
Medications
Food
General Consent Form

TO THE PATIENT: You have the right to be informed about your condition and the recommended surgical, medical, or diagnostic procedure so that you may make the decision whether to undergo a recommended suggested treatment plan. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the propriate treatment or procedure for any identified condition(s).

By signing this form, you indicate that:

You voluntarily request a physician or mid-level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), other health care providers, or the designees, as deemed necessary, to perform reasonable and necessary medical examination, testing, and treatment for the condition which has brought you to seek care at this practice.

You intend that this consent is continuing in nature even after a specific diagnosis is made and treatment recommended.

You consent to treatment at this office, any other satellite office under common ownership, in your place of residence, or via telemedicine and video.

You consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

You understand that:

You have the right at any time to discontinue services.

You have the right to discuss the treatment plan with your physician/provider about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions.

Telemedicine services involve the use of secure interactive videoconferencing equipment and devices that providers to deliver health care services to patients when located at different sites.

The same standard of care applies to telemedicine as applies to an in-person visit.

You will not be physically in the same room as your health care provider during telemedicine services.

You will be notified, and your consent will be obtained for anyone other than your healthcare provider present in the room.

There are potential risks to using technology, including service interruptions, interceptions, and technical difficulties.

If the video conferencing equipment or connection is not adequate, your healthcare provider or you may discontinue the telemedicine visit and make arrangements to continue the visit.

You have the right to refuse to participate or decide to stop participating in a telemedicine visit. Your refusal will be documented in your medical record. Your refusal will not affect your right to future care or treatment.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment, or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.
You understand that:

Protected health information may be disclosed or used for treatment, payment, or healthcare operations.

The practice may condition receipt of treatment upon execution of this consent.

The laws that protect privacy and the confidentiality of health care information apply to telemedicineservices.

The practice reserves the right to change the privacy policy as allowed by law.

The practice has the right to restrict the use of health information but the practice does not have to agree tothose restrictions.

An indirect financial relationship permitted under Texas Occ.Code 102.001 exists between this clinic andcertain pharmacies and laboratories, to whom you may be referred, for prescriptions and lab work. Youhave the right to request services provided by other laboratories and pharmacies.

You have the right to revoke this consent in writing at any time and all full disclosures will then cease.

Your consent will remain fully effective until revoked in writing.

I HEREBY PROVIDE INFORMED CONSENT TO DIA HEALTH TO USE PHONE OR SEND TEXT MESSAGES TOCONFIRM APPOITNMENTS, ALSO TO LEAVE A VOICEMAIL WHEN REQUIRED.I HEREBY PROVIDE CONSENT TO REQUEST, VIEW, AND USE MY EXTERNAL MEDICAL ANDPRESCRIPTION RECORDS FOR TREATMENT PURPOSES AND TO OPT IN FOR TEXT MESSAGES NOTIFICATIONS.
Initial here if you authorize us to discuss your medical condition with a member of your family.*
Please name the members allowed:*
May we discuss your medical condition with any member of your family? If YES, please name the members allowed
By signing this form, I attest that I (1) have personally read this form (or had it explained to me) and fully understand and agree to its content; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine and home visits shared with me in a language I understand; and (3) am located in the state of Texas and will be in Texas during (Initial my telemedicine or home visit(s).
(Initial).*
TO THE PATIENT: You have the right to be informed about your condition and the recommended surgical, medical, or diagnostic procedure so that you may make the decision whether to undergo a recommended suggested treatment plan. This consent form is simply a CONSENT FORM.

I understand that I have certain rights to privacy regarding my protected health information (PHI These rights are given to me under the Health Information Portability and Accountability Act of 1996 (HIPAA I understand that by signing this (Initial consent I authorize Dia Health to use and disclose my PHI in the following ways:
(Initial).*
Treatment (including direct or indirect treatment by other healthcare providers involved with my care and requests to obtain or release medical records from other physicians or facilities as necessary);

Obtaining payment from third party payer (e.g. My insurance company);

The day-to-day healthcare operations of Dia Health practice, including sharing with third-party vendors, some of which may require separate consent;

You understand that the third-party vendors who ask for my PHI are legally obligated to abide by the requirements of the HIPAA and are required to maintain the security and confidentiality of my information. I understand that if I wish to optimize my experience and enhance the continuity of my care, I must voluntarily opt-in by providing express consent (below) to sharing my information with third- party vendors.

You have also been informed of and given the right to review and receive a copy of the Joint Notice of Privacy Practices, which includes a description of the use and disclosure of my PHI, and my rights under HIPAA. I understand that you may change the terms of this Notice from time to time and that I can always ask for a current copy of the Notice.

You understand that I can request restrictions on how my PHI is used and disclosed to carry out treatment, payment, and health care operation, and that you are then required to comply with this restriction.

I understand that I can revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date consent is revoked will not be affected.
Printed Name of Patient or Personal Representative*
Date*

MonthDayYear
Date
Signature of Patient or Personal Representative*

Clear
Date

MonthDayYear
Date
Safety Policy

Dia Health PLLC is required to report abuse or unsafe conditions to APS/CPS. All clinicians are bound by law to submit a report to the appropriate authorities if known or suspected abuse or unsafe conditions are present.

Any rude or disruptive behavior by anyone in the clinic will not be tolerated and be grounds for immediate suspension and/or possible termination/dismissal from the practice.

Any rude behavior or cursing from the patient, caregiver, family, friends, or anyone else in the clinic to any Dia Health PLLC staff member will not be tolerated. All interactions may be externally reviewed by Dia Health PLLC administration. The patient may be dismissed from the practice immediately in such cases at the discretion of Dia Health PLLC administration; this final decision is not made by the clinicians.

No weapons are permitted to be visible or brandished during interactions with staff. Failure to maintain a safe and non-threatening environment will result in immediate cessation of services and result in immediate termination from practice.

I acknowledge that certain tests can be performed at Dia Health. Patient has the right to use the lab of their choosing fir these tests such as, Covid Lites, RPP and, UTI.

Any pets are not allowed in clinic, this also includes service dogs and emotional support animals that may be a threat. If these measures are not met, this will constitute suspension. NO EXCEPTIONS.
Printed Name of Patient or Personal Representative*
Date*

MonthDayYear
Date
Signature of Patient or Personal Representative*

Clear
Date*

MonthDayYear
Date
Acknowledgement of Notice of Privacy Practices

I certify that I have received a copy of Dia Health's Notice of Privacy Practices.

The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment of my bills or in the performance of Dia Health care operations. The Notice of Privacy Practices also describes my rights and the duties of Dia Health with respect to my protected health information.

Dia Health reserves the right to change the privacy practices at any time and I may obtain a revised copy by calling the office and requesting a copy to be sent in the mail or asking for one at the time of my next appointment.
Signature*

Clear
Print*
Date*

MonthDayYear
Date
Chronic Care Agreement Form

As a patient with two or more chronic conditions (such as but not limited to DM, HTN, HLD, weight management, (CHF, CKD, RA), you may benefit from a program that Dia Health offers all Medicare patients through Medicare. Our goal is to make sure you get the best care possible from everyone that is involved with your care. We can help coordinate your visits with other doctors, facilities, lab, radiology, or other testing; we can talk to you on the phone about your symptoms; we can help you with the management of your medications; and we will provide you with a comprehensive care plan. Medicare will allow us to bill for these services during any month that we have provided at least 20 minutes of non-face-to-face care of you and your conditions which includes but is not limited to coordinating referrals, prior authorizations for medications, and obtaining records.

You must provide your consent to participate once a year. Your assigned clinician in charge of your care is Dr. Ricardo Aguilar. Sometimes other staff from our practice will talk to you or handle issues related to your care (physician assistant (PA) nurse practitioner (NP), but please know that your assigned clinician will supervise all care provided by our staff or clinicians who may be involved in your care.

You agree and consent to the following:

As needed, we will share your health information electronically with others involved in your care. Please rest assured that we continue to comply with all laws related to the privacy and security of your health information.

We will bill Medicare for this chronic care management for you once a month. The fee for this service allowed by Medicare is charged to your insurance and is variable depending on your insurance of which your portion will depend on deductible and plan. Although you may not come into the office every month, your account will reflect this charge and you will be responsible for payment. Our office will have a record of our time spent managing your care if you ever have a question about what we did each month.

Only one physician can bill for this service for you. Therefore, if another one of your physicians has offered to provide you with this service, you will have to choose which physician is best able to treat you and all your conditions. Please let your physician or our staff know if you have entered into a similar agreement.

You have the right to:

A Comprehensive Care Plan from our practice to help you understand how to care for your conditions so that you can be as healthy as possible.

Discontinue this service at any time for any reason. Because your signature is required to end your chronic care management services, please ask any of our staff members for the CCM termination form.
Our goal is to provide you with the best care possible, to keep you out of the hospital, and to minimize costs and inconvenience to you due to unnecessary visits to doctors, emergency rooms, labs or hospitals. We know your time and your health is valuable and we hope that you will consider participation in the program with our practice. I agree to participate in the Chronic Care Management program.
Signature*

Clear
Date*

MonthDayYear
Date
Telemedicine Informed Consent

Telemedicine services involve the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patients when located at different sites.

1. I understand that the same standard of care applies to a telemedicine as applies to an in-person visit.

2. I understand that I will not be physically in the same room as my health care provider. I will be notified of, and my consent obtained for anyone other than my healthcare provider present in the room.

3. I understand that there are potential risks to using technology, including service interruptions, interceptions, and technical difficulties. If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that my healthcare provider or I may discontinue the telemedicine visit and make arrangements to continue the visit.

4. I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit or home visit, and that my refusal will be documented in my medical record. I also understand that my refusal will not affect my right to future care or treatment. a. I may revoke my right at any time by contacting Dia Health at 210-290-8350.

5. I understand that the laws that protect privacy and the confidentiality of health care information apply to telemedicine services.

6. I understand that my health care information may be shared with other individuals for scheduling and billing purposes.
a. I understand that my insurance carrier will have access to my medical records for quality review/audit.
b. I understand that I will be responsible for any out-of-pocket costs such as co- payment or coinsurances that apply to my telemedicine visit.
c. I understand that health plan payment policies for telemedicine may be different from policies for in-person visits.

7. I understand that this document will become a part of my medical record.

By signing this form, I attest that I (1) have personally read this form (or had it explained to me) and fully understand and agree to its content; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine visits shared with me in a language. I understand; and (3) am located in the state of Texas and will be in Texas during my telemedicine visit(s).
Signature*

Clear
Printed name*
Date*

MonthDayYear
Date
If you required assistance to read this form, name of person assisting you
Pain Treatment with DEA (Drug Enforcement Agency) Controlled Medications: Patient Agreement
a. I, ____________ , understand and voluntarily agree that I will never be prescribed, which includes refills from originally prescribed from other providers, any controlled medication from any provider in practice at Dia Health, or:
Name*

First NameLast Name
b. I, ____________ , understand and voluntarily agree that (inital after each statement after reviewing):
Name*

First NameLast Name
I will keep (and be on time for) all my my scheduled appointments with the doctor and other members of the treatment team.
Initial.*
I will participate in all other types of treatment that I am asked to participate in.
Initial.*
I will keep the medicine safe, secure and out of the reach of children. If the medicine is lost or stolen, I understand it will not be replaced until my next appointment and may not be replaced at all.
Initial.*
I will take my medication as instructed and not change the way I take it without first talking tothe doctor or other member of the treatment team.
Initial.*
I will not call between appointments, or at night or on the weekends looking for refills. Iunderstand that prescriptions will be filled only during scheduled office visits with the treatment team.
Initial.*
I will make sure I have an appointment for refills. If I am having trouble making an appointment, I will tell a member of the treatment team immediately.
Initial.*
I will always treat the staff at the office respectfully. I understand that if I am disrespectful to staff or disrupt the care of other patients my treatment will be stopped.
Initial.*
I will not sell this medicine or share it with others. I understand that if I do, my treatment will be stopped.
Initial.*
I will sign a release form to let the doctor speak to all other doctors or providers that I see.
Initial.*
I will tell the doctor all other medicines that I take and let him/her know right away if I have a prescription for a new medicine.
Initial.*
I will use only one pharmacy to fill my prescriptions for controlled medications:
Initial.*
Pharmacy Name*
Phone #
I will not get any opioid pain medicines or other medicines that can be addictive such as benzodiazepines (klonopin, xanax, valium, norco) or stimulants (ritalin, amphetamine) without telling a member of the treatment team before I fill that prescription. I understand that the only exception to this is if I need pain medicine for an emergency at night or on the weekends.
Initial.*
I will not use illegal drugs such as heroin, cocaine, marijuana, or amphetamines. I understand that if I do, my treatment will be stopped.
Initial.*
I will come in for drug testing and counting of my pills within 24 hours of being called. I understand that I must make sure the office has current contact information in order to reach me, and that any missed tests will be considered positive for drugs.
Initial.*
I will keep up to date with any bills from the office and tell the doctor or member of the treatment team immediately if I lose my insurance or cannot pay for treatment anymore.
Initial.*
I understand that I may lose my right to treatment in this office if I break any part of this agreement.
Initial.*
Controlled Medication Treatment Program Statement:

We here at Dia Health are making a commitment to work with you in your efforts to get better. To help you in this work, we agree that:

We will help you schedule regular appointments for medicine refills. If we have to cancel or change your appointment for any reason, we will make sure you have enough medication to last until your next appointment.

We will make sure that this treatment is as safe as possible. We will check regularly to make sure you are not having side effects.

We will keep track of your prescriptions and test for drug use regularly to help you feel like you are being monitored well.

We will help connect you with other forms of treatment to help you with your condition.

We will help set treatment goals and monitor your progress in achieving those goals.

We will work with any other doctors or Providers you are seeing so that they can treat you safely and effectively.

We will work with your medical insurance providers to make sure you do not go without medicine because of paperwork or other things they may ask for.

If you become addicted to these medications, we will help you get treatment and get off of the medications that are causing you problems safely.
Patient name*
Date*

MonthDayYear
Date
Patient Signature*

Clear
Provider name
Authorization For Disclosure of Health Information
Patient Name
Date of birth

MonthDayYear
Date
Address

Address

Street Address Line 2

City/StateState / Province

Zip code
Phone number
II. Information to be disclosed.
I authorize Dia Health PLLC to disclose my health information as follows
Select all that apply

All Paper chart recordsEntire medical record/outpatient clinical recordHistory and PhysicalsOperative Report(s)Discharge summary(ies)Films and PicturesAll Electronic medical recordsLaboratory resultsRadiology and Imaging ResultsPathology slides, blocks, or reportsOther test resultsOther
I understand that information used or disclosed pursuant to this authorization form may include information relating to Human Immunodeficiency Virus (HIV) or Acquired Immunodeficiency Syndrome (AIDS); treatment for or history of drug alcohol abuse; or mental or behavioral health or psychiatric care.

III. Information to be disclosed To /From:
Disclosed To:

Name: Dia Health PLLC

Address: 2515 Castroville Rd., Ste 1

City, St, Zip: San Antonio, TX 78237

Phone: 210-290-8350

Fax: 210-290-8325
V. I authorize the disclosure of health information as described above. I understand:
This authorization is valid for 180 days unless otherwise stated

A photocopy or fax of this authorization is as valid as the original.

I may revoke this authorization at any time by submitting a revocation in writing to Dia Health PLLC.

If I revoke this authorization, the revocation will not apply to information that has already been released in good faith before the revocation was recieved.

Treatment or payment may not be conditioned on my completeion of this authorization form.
Signature*

Clear
Date*

MonthDayYear
Date
Signature of Qualified Personal Representative*

Clear
United Healthcare

Attn: Member Services
Fax: 1-844-881-4857

Primary Care Provider (PCP) Change Request Form

UnitedHealthcare Medicare Advantage plan members can change their PCP at any time and for any reason. You can help members change their PCP by returning this completed form to UnitedHealthcare, or they can call the toll-free number on their member ID card.

We will process the request within 5-7 business days and the change will be effective on the first day of he next month.

Note: This PCP change won't affect any referrals submitted by the member's former PCP.

Before you send, make sure:
To visit uhcprovider.com to check the member's current PCP and confirm a change is needed

The form is filled out completely

The form is signed by the member

To use a seperate form for each member

Fax the completed form to:

UnitedHealthcare Member Services
Fax: 1-844-881-4857
Member Information
Name

First NameLast Name
Address
City
State
Zip
Phone Number
Date of Birth

MonthDayYear
Date
Member ID#
Reason for changing PCP
Do you need a new member ID card?

YesNo
Signature*

Clear
Date

MonthDayYear
Date
When I sign above, I am stating that I want to change my PCP to the provider listed on the next page. By filling out and faxing this form, I am authorizing UnitedHealthcare to change my PCP.
Provider Information
Name of previous PCP
Name of new PCP
Practice name
NPI
TIN
Address
City
State
Zip
Name of the staff completing this form with member
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract. Enrollment in the plan depends on the plan's contract renewal with Medicare.

The company does not discriminate on the basis of race, color, national orgin, sex, sex, age, or disability in in health programs and activites.

We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the member toll-free phone number listed on your ID card.
Should be Empty: