Pair Team x Understood Care

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org

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GCLID

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utm_content

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utm_campaign

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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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Patient Full Name* This field is required.

First Name

Last Name

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Patient Date of Birth* This field is required.

Date

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Patient Phone Number* This field is required.

Please enter a valid phone number.

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Please enter the Medicare Beneficiary Identifier (MBI).* This field is required.The MBI is the 11-character number on the front of the patient's red, white, and blue Medicare card (e.g., 1EG4-TE5-MK72).

e.g. 1EG4-TE5-MK73

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Patient Email

example@example.com

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Please upload the patient's medical record and relevant visit notes.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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Please review and confirm all of the following to proceed.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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One of our team members will call you as soon as they’re available during your preferred time of day — or, if you prefer, you can choose a time that works best for you here.

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submission_source_trait

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payer_trait