Please complete and submit this form with your enrollment application. If you can answer “Yes” or “Not sure” to any of the following questions, you may be eligible to join our Chronic Special Needs Plan. When this form is completed and submitted along with an enrollment application, you will be enrolled into ATRIO Health Plans. We will attempt to verify your chronic condition(s) with your provider during the first month of enrollment. If we are unable to verify your chronic condition(s), we are required to disenroll you from the Chronic Special Needs Plan. If you do not qualify for this plan, ATRIO Health Plans has other plan options in this county.
