CALL 1-800-288-9931

Please Sign This Form to Tell Medicare that the provider you list is your Primary Healthcare Provider.

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.

Your provider is voluntarily taking part in this new initiative by joining the Accountable Care Coalition of Direct Contracting because we think 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 Accountable Care Coalition of Direct Contracting.

In partnership with your provider, Accountable Care Coalition of Direct Contracting will coordinate your care with specialists and other healthcare providers in your community to make sure you receive the right care at the right time, removing potential barriers for better access to care while empowering you to be actively involved in your own healthcare decisions. You may even experience additional benefits and enhancements. For people with complex conditions, for example, your provider may introduce you to a care coordinator, at no additional fee, to help you maintain your best health.

You can use this form 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 Accountable Care Coalition of Direct Contracting 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 Medicare.gov and select your main doctor or other health care professional in order to determine whether Accountable Care Coalition of Direct Contracting 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 Accountable Care Coalition of Direct Contracting at 1-800-288-9931, 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 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 1-800-288-9931 or update your online selection if you change your mind later about whether you consider this provider 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 here.






    Please enter the alpha-numeric identifier provided to you.

















    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 Accountable Care Coalition of Direct Contracting at 1-800-288-9931 to request a form.

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