Patient Confirmation Form
Please Sign This Form to Tell Medicare that the provider you list is your Main 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 ilumed because we believe 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 ilumed.
In partnership with your provider, ilumed will work as your patient advocate by using an integrated “concierge” approach by removing potential barriers for better access to care. The goal is to deliver care and access at the right time and in the right place by the right provider while empowering you to be actively involved in your healthcare decisions.
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 ilumed 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 completing this form, you can also log into Medicare.gov and select your main doctor or other health care professional in order to determine whether ilumed should help with coordinating your care. Instructions for navigating Medicare.gov are included with this letter. If you make a selection on this form and make a different selection through Medicare.gov, Medicare will prioritize the most recently submitted selection.
Complete the form with your information, check the box agreeing to use your electronic signature and then click the “submit” box.
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 ilumed at 800-481-8745, 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.
Confirm your doctor below. We’ll do the rest.
Please fill in the information below about your primary doctor or other healthcare professional that you see for routine medical care. Submit the form and you are well on your way to more modern, more personalized care.
Thank you for submitting the ilumed DCE Confirmation Form.
We have successfully received your information!
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 ilumed at 1-800-481-8745 to request a new form.