Verification of Chronic Conditions

To remain enrolled in the Chronic Conditions (C-SNP) plan all members must have their chronic conditions verified either internally by the SNP team or through their Primary Care Physician. The following form must be completed by a provider in a timely manner for the member to qualify for, and remain enrolled, in the plan. Below are the Chronic Conditions the provider must verify (only one condition is needed to qualify for the plan).

Diabetes Type 1 or 2
Congestive Heart Failure
Cardiovascular Disease

We at ATRIO try our best to verify these conditions for our incoming members ourselves, but ensuring this form reaches your provider is the very best way to complete that step of the process. Without condition-verification, C-SNP members will be disenrolled from the plan so verification is of the utmost importance.

All required fields are marked with an asterisk(*).

Y0084_MBR_VCC_2027_C

Member's First and Last Name:

Date of Birth:

Medicare ID Number:

ATRIO Member ID:

Member's Phone Number:

What is your relationship to the Member?

Primary Care Physician
Other

If Other, please provide additional details:

Submitter's Full Name:

Submitter's Title

Office Phone Number:

Fax Number:

NPI / TIN:

Submitter's Signature:

Verification of Chronic Conditions

Company

Compliance at ATRIO

Resources

Disclosures