List the provider or practice you are confirming as your main doctor or other healthcare provider – or the main place you go to for routine medical care.

 

Example: John Smith

 

Example: 1EG4-TE5-MK72

 
 
mm/dd/yyyy
 

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