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Disclaimer

  1. Whether or not you complete this Voluntary Alignment Form, 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. You may return the Voluntary Alignment Form to a CareConnectMD at Home representative at your facility, or send it in the postage paid return envelope to the following address:

    CareConnectMD at Home

    Attention: Patricia Flood

    3090 Bristol Street, Suite 100

    Costa Mesa, CA 92626

  2. Completing the Voluntary Alignment Form is your choice and you can change your mind later. This online form below will simply help determine if CareConnectMD at Home can help provide improved care and better service for you. If you select CareConnectMD at Home (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.

  3. You can also do it online through www.MyMedicare.gov and we can provide you with instructions how to do so HERE. 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.

  4. If you have questions, feel free to call CareConnectMD at Home at 888-874-0818. You can also call Medicare at 1-800-MEDICARE (1-800-633-4227) to ask about “DCE’s”. TTY users should call 1-877-486-2048.

  5. If you change your mind later about whether you consider CareConnectMD at Home to be the main doctor or other healthcare professional you see for routine care, you can call 888-874-0818 or update your selection online, at anytime.

Please fill out this form below to see if you qualify for CareConnectMD at Home and a member of our team will contact you!