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 $MEDICALGROUP] is voluntarily taking part in this new initiative by joining Arizona Priority Care REACH ACO (AZPC REACH) because we think it will help us provide better quality care for our patients.
You are receiving this letter and form because your doctor or other health care professionals thinks that you might benefit from care coordination and preventive services offered by AZPC REACH.
For more information about the health care services you are entitled to receive, contact AZPC REACH at 480-336-7444.
You can use this form to confirm that [$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 $MEDICALGROUP] to be the main doctor or other healthcare professional you see or the main place you go for routine care.
Get more information about ACOs.
CMS Website: https://innovation.cms.gov/innovation-models/aco-reach
ACO Website: https://azprioritycare.com/for-patients/traditional-medicare-reach-aco/
By signing below I am confirming that my main doctor or the healthcare professional - or the main place I go for routine medical care - is [$PROVNAME OR $MEDICALGROUP].
Your Medicare Beneficiary Idenetifier (MBI) has 11 characters and can be found on your Medicare card.
Note: This is NOT your Social Security Number
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.
Your form was successfully submitted
CMS Approval #CS1638361 04_17_2023
Arizona Priority Care became aware of a data breach. Please click here for more details.