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

You can use the form provided to confirm your main doctor or other health care professional or the main place you go for routine care. Routine care can include regular care and check-ups you get from a doctor or other health care professional and care for other chronic health problems, such as asthma, diabetes, and hypertension.
Alternatively, instead of returning the form provided, you can also log into Medicare.gov and select your main doctor or other health care professional. If you make a selection on this form and make a different selection through Medicare.gov, Medicare will prioritize the most recently submitted selection.

Your Medicare Benefits Are Not Changing & You Always Have a Choice

By completing this form your general Medicare benefits will not change. You can visit any doctor, other health care professional, or hospital. You always have the option to change or select a doctor or other health care professional through Medicare.gov at any time. You can also change your mind at a future date and select a new doctor. You should be the one to select your health care professionals, no one else should complete this for you.

No one is allowed to attempt to influence your choice to complete this form or select a doctor or other health care professional through Medicare.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.

Find more information about DCEs by visiting the CMS Website:
https://innovation.cms.gov/innovation-models/gpdc-model