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Email
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Your email
Agent
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Patient Name
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Community Healthcare Advocates
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Steven Vargas - Community Health Care Manager
Oralia Flores - Community Health Care Supervisor
Iliana Escrigas - Community Health Care Advocate
Doreen Garza - Community Health Care Advocate
Beatriz Gomez - Community Health Care Coordinator
Patient DOB
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MM
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DD
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Patient's Address
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City and Zip Code
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Patient Phone Number
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Patient Medicare ID/Health Plan ID (Optional)
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Doctor
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Effect Date
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DD
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YYYY
Insurance Plan
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Cigna Total-Care (HMO D-SNP) - H4513-060-004
Cigna Preferred Medicare (HMO) - H4513-061-004
Cigna Preferred Savings Medicare (HMO) - H4513-083-004
Cigna Courage Medicare (HMO) - H4513-009-000
Devoted Health Core San Antonio (HMO) - H7993-003-000
Devoted Health Prime San Antonio (HMO) - H7993-004-000
Devoted BeWell San Antonio (HMO C-SNP) - H7993-005-000
Hum (MC) Gold Plus (HMO) - H0028-030-000
Hum (MC) Gold Plus SNP-DM Heart (HMO C-SNP) - H0028-039-000
Hum (MC) Gold Plus SNP-DE (HMO D-SNP) - H0028-036-000
Hum (MC) Gold Plus SNP-DE (HMO D-SNP) - H0028-064-000
SCAN Classic (HMO) - H8902-001-000
SCAN Balance (HMO C-SNP) - H8902-002-000
SCAN Heart First (HMO C-SNP) - H8902-003-000
SCAN Venture (HMO) - H8902-004-000
SCAN Strive (HMO C-SNP) - H8902-009-000
AARP Medicare Advantage (HMO) - H0609-063-000
AARP Medicare Advantage (HMO) - H0609-067-000
AARP Medicare Advantage (HMO) - H0609-071-000
AARP Secure Horizons Medicare Advantage (HMO) - H0609-050-000
AARP Medicare Advantage Patriot (HMO) - H0609-056-000
UHC Dual Complete (HMO D-SNP) - H0609-065-000
UHC Dual Complete (HMO D-SNP) - H0609-053-000
UHC Complete Care (HMO D-SNP) - H0609-058-000
UHC Dual Complete (HMO D-SNP) - H4515-021-000
Wellpoint Dual Advantage (HMO D-SNP) - H8849-011-003
Wellpoint Dual Advantage 2 (HMO D-SNP) - H2593-032-000
Wellpoint Full Dual Advantage 2 (HMO D-SNP) - H2593-051-000
Wellpoint Medicare Advantage 2 (HMO) - H2593-029-000
Wellpoint Select (HMO) - H8849-006-000
Is this a referral?
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New GMG Patient
Existing Gonzaba Patient - "New to MAPD"
Existing Gonzaba Patient - "Plan Change"
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