Participate in PCMH

Privacy is a Priority

If you have multiple chronic conditions, you may benefit from the PCMH Program. Talk to your PCP for more information.

If your PCP has already asked you to participate in the PCMH Program, simply read then sign the appropriate Election to Participate form below and return it to your PCP. You may also request this form from your PCP.

This form is not required for the Blue Rewards incentive program.

• Election to Participate Form
• Election to Participate Form - Spanish version
• Election to Participate Form - Korean version

NOTE: Due to strict privacy policies, your PCP is required to obtain a signed Election to Participate form from you on an annual basis. Please make sure your PCP has a current Election to Participate form on file.

If you decide you no longer want to participate in PCMH, you must fill out the appropriate Revocation of Election to Participate form below.

• Revocation of Election to Participate
• Revocation of Election to Participate - Spanish version
• Revocation of Election to Participate - Korean version

For more information, review Privacy is a Priority.