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Main Doctor or Primary Clinician Selection

Select Your Main Doctor or Primary Clinician:


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

[$PROVNAME OR $MEDICALGROUP] is voluntarily taking part in this new initiative by joining Arizona Priority Care REACH ACO (AZPC REACH) 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 professionals thinks that you might benefit from care coordination and preventive services offered by AZPC REACH.

AZPC REACH provides additional services at no cost to you, including:
  • Additional Traditional Medicare Benefit Enhancements
  • Benefit Engagement Incentives for the Management of Chronic Conditions
  • In-Home Assessments & Care Coordination by a Nurse Practitioner
  • Care Management and Post-Discharge services provided by a Registered Nurse

For more information about the health care services you are entitled to receive, contact AZPC REACH at 480-336-7444.

You can use this form to confirm that [$PROVNAME OR $MEDICALGROUP] is the main doctor or other health care professional you see or the main place you go for routine care, to help determine if AZPC REACH should help coordinate your care. Routine care can include regular care and check-up 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 AZPC REACH 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 AZPC REACH at 480-336-7444, 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 480-366-7444 or update your online selection if you change your mind later about whether you consider [$PROVNAME OR $MEDICALGROUP] to be the main doctor or other healthcare 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/aco-reach
ACO Website: https://azprioritycare.com/for-patients/traditional-medicare-reach-aco/

Confirm and Submit

By signing below I am confirming that my main doctor or the healthcare professional - or the main place I go for routine medical care - is [$PROVNAME OR $MEDICALGROUP].

*Required Fields

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 Arizona Priority Care REACH ACO at 480-336-7444 to request a new form.

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

Signature Verification Statement

  • I consent to signing this Form electronically.
  • I agree that my electronic signature is the legal equivalent of my handwritten signature on this Form and further that my signature on this document is as valid as if I had signed the document in writing.
  • I agree that no certification authority or other third party verification is necessary to validate this signature and that this is a legally binding document between me and [$PROVNAME OR $MEDICALGROUP].
  • I am confirming that I am a Medicare beneficiary authorized to complete this Form.



CMS Approval #CS1638361 04_17_2023