CARY ADULT MEDICINE - Publicforms

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Voluntary Alignment for Medicare ACO REACH

First Name *

Last Name *

Street Address *

City and Zip Code *

Date of Birth *

Your Medicare Number *

This number can be found on your Medicare ID Card and is 11 characters made up of letters and numbers

Todays Date *

Primary Care 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 an Accountable Care Organization (ACO), to work together with Medicare to give you more coordinated care and services.

Cary Adult Medicine is voluntarily taking part in this new initiative by joining Upstream because we think it will help us provide better quality care for our patients. Upstream has partnered with primary care providers to: Increase satisfaction and improved health, Reduce hospital admissions, Reduce burden and stress for informal caregivers

You can use this form to confirm that Cary Adult Medicine is the main doctor or other health care professional you see or the main place you go for routine care, to help determine if Upstream 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 complete this form by validating your intent with a digital signature below.

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 UpStream at 336-860-1211, 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 888-333-0477 or update your online selection if you change your mind later about whether you consider Cary Adult Medicine to be the main doctor or other health care professional you see or the main place you go for routine care. Sincerely, Cary Adult Medicine Robert Resnik MD Laura Lisicki FNP

By typing name and hitting the submit button below you are certifying you are the above named individual and have made a decision to choose the above name provider at Cary Adult Medicine as your primary care physician.

Please 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 Upstream Gap-Q at 888-333-0477 to request a new form.

Please also Note: Completing and returning this form is voluntary. It won?t affect your Medicare benefits

Signature Field *

Please type your name. By typing your name and hitting the submit button you are certifying you are the above named individual. You have read and agree with the statements above and have chosen the above provider as your primary care physician and understand that Medicare will assign this provider as your primary care physician. Your benefits will not change. You have the right to change primary care providers at any time.

Get more information about ACOs. CMS website: https://innovation.cms.gov/innovation-models/aco-reach or Upstream GAP- Q https://www.upstream.care/upstream-gap-q

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