NOTE: Whether or not you complete this form or select Bloom Healthcare as your main doctor or other health care professional, 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. This form will simply help determine if Hana Hou Medical Group can help provide improved care and better service for you.

Selecting HHMG or any other doctor or other health care professional by completing this form is your choice AND you can change your mind later. If you complete this form and select HHMG (or any other doctor) as your main doctor or health care professional, you should do so yourself. No one else, other than a Power of Attorney or Legal Guardian, should complete this form for you.

You can also do it online through www.MyMedicare.gov. Whatever is easiest for you! If you make a selection on this form and make a different selection through MyMedicare.gov, Medicare will prioritize the selection you make through MyMedicare.gov. No one is allowed to attempt to influence your choice to complete this form or select a doctor or other health care professional through MyMedicare.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.

If you have questions, feel free to call HHMG at 888-621-0230. You can also call Medicare at 1-800-MEDICARE (1-800-633-4227) to ask about “DCEs”. TTY users should call 1-877-486-2048.

If you change your mind later about whether you consider HHMG to be the main doctor or other health care professional you see for routine care, you can call (888) 621-0230 or update your selection online, at anytime.

Importante: esta informacion esta disponibles en espanol, solicitalo llamando al (720) 923-1302.

You can also get more information about DCEs at the CMS Website: https://innovation.cms.gov/initiatives/direct-contracting-model-options