Chronic Care Management

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GCLID

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utm_content

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utm_campaign

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campaign_id

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utm_term

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keyword_id

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program

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ad_name

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network

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utm_source

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utm_medium

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FBCLID

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msclkid

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ours_user_id

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What is your name?* This field is required.

First Name

Middle Name

Last Name

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What is your date of birth?* This field is required.

Date

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Please provide your phone number.* This field is required.By sharing your phone number, you consent to phone & SMS communications from Pair Team. (We never share or sell your personal information!)

Please enter a valid phone number.

19

Please enter your Medicare Beneficiary Identifier (MBI).* This field is required.As shown on your red, white, and blue Medicare card (11-character ID).

e.g. 1EG4-TE5-MK73

20

Finally, please share your email.

example@example.com

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Please review and confirm all of the following to proceed.* This field is required.View Pair Team's Privacy Policy and Chronic Care Management Services Consent.

I agree to the Privacy Policy.

I consent to participate in the Chronic Care Management Program.

I authorize the release of information to process and adjudicate claims.

I authorize the payment of benefits to provider.

I confirm that I have active Medicare Part B coverage.

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submission_source_trait

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payer_trait