West Salem Family Practice Confirmation of Main Doctor or Other Healthcare Professional Form

Provider - Clinic*

List the provider you are confirming as your main doctor or other healthcare provider.

Your Name (First Last)*

Example: John Smith

Medicare Beneficiary Identifier (MBI)*

Example: 1EG4-TE5-MK72

Todays Date*

Signature (re-enter name)*

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.

Send me a copy of my responses