CSNP Preenrollment Qualification Assessment Tool | ATRIO Health Plans

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ATRIO Health Plans Medicare Advantage (PPO C-SNP) is designed for people with chronic conditions such as diabetes, chronic heart failure and certain cardiovascular disorders.

Enrollee Information

First Name *

Last Name *

MI

Medicare ID Number

Phone Number *

Birthdate

Chronic Condition Questions

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.

Have you been diagnosed with diabetes?

Yes
No
Not Sure

Have you had prior blood test that indicate problems with high blood sugar?

Yes
No
Not Sure

Do you take medication and/or have you been put on a special diet to control your blood sugar?

Yes
No
Not Sure

Have you been diagnosed with chronic (or congestive) heart failure (CHF)?

Yes
No
Not Sure

Have you had problems with fluid retention in your lungs or swelling in your legs due to a heart problem?

Yes
No
Not Sure

Do you take medication to prevent fluid retention?

Yes
No
Not Sure

Have you been diagnosed with any of the following cardiovascular disorders? Cardiac arrythmia, Chronic venous thromboembolic disorder, Coronary artery disease, or Peripheral vascular disease

Yes
No
Not Sure

Have you had problems with rapid, erratic heartbeats?

Yes
No
Not Sure

Have you had problems with chest pain or tightness, shortness of breath, heart attack, or stroke?

Yes
No
Not Sure

Has a physician ever told you that you have a blood clot?

Yes
No
Not Sure

Health care provider(s) who can verify your chronic condition(s)

Provider Name *

Provider Address

Provider Phone

Provider Fax

Would you like to add a second provider?

No.2 Provider Name *

No.2 Provider Address

No.2 Provider Phone

No.2 Provider Fax

Authorization for Disclosure of Health Information to Verify Chronic Condition(s):
I hereby authorize the disclosure of my health information by the providers listed above to ATRIO Health Plans in order to verify that I have been diagnosed with a chronic condition which qualifies me for enrollment in ATRIO Health Plans Chronic Special Needs Plan. This authorization applies to all health information maintained by the provider concerning my medical history for the chronic condition(s) indicated on the first page.

Note: Information disclosed as a result of this authorization will be protected by ATRIO Health Plans in accordance with applicable state and federal laws and requirements.

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