WEB Thurston Medical Clinic Confirmation of Main Doctor or Other Healthcare Professional Form

Provider or Practice

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.

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