Provider Confirmation Form

Provider Confirmation Form

By signing below I am confirming that my main doctor or other healthcare professional – or the main place I go to for routine medical care – is the provider listed below.

South Salem Primary Care LogoPraxis Care LogoCMS logo

You were asked to complete this form because your doctor or other health care professional thinks that you might benefit from care coordination and preventive services offered by PraxisCare.

You can use the form above to confirm that South Salem Primary Care is the main doctor or other health care professional you see or the main place you go for routine care, to help determine if PraxisCare 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.

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, or call the local clinic, PraxisCare at 1-888- 816-0416, 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 (888) 816-0416 or update your online selection if you change your mind later about whether you consider South Salem Primary Care to be the main doctor or other health care professional you see or the main place you go for routine care.

Sincerely,

South Salem Primary Care & PraxisCare