I understand that I may call my personal doctor at any time for
medical advice, care or a referral if myself or anyone in my family covered by HealthChoice is sick or injured.
I understand that unless I have a medical emergency, I must contact
my personal doctor for medical care. I understand that in an emergency, I must contact my
personal doctor or the Managed Care Organization (MCO) as soon as possible, after I have
received emergency care.
I understand that I am choosing to enroll in the MCO indicated and
selecting a primary care doctor for myself and for each family member on this form.
I understand that receiving health care services without my personal
doctor or MCO approval may result in a denial of payment by the MCO and may result in my
being billed for the service. HealthChoice
is not responsible for the bill and will not pay for the services if I do not follow the
required directions of the MCO.
I understand that, after twelve months, I may change MCO once a year
without giving a reason and that I may change MCOs at any time with an approved reason and
that I can call the HealthChoice
Enrollment line for help.
I understand that it is my responsibility to notify the MCO and my
caseworker of any change in the number of my family members.
I understand that I must follow Medical Care Program regulations to
stay eligible for HealthChoice.
I understand that all information is confidential. |
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