Congratulations on joining a Chronic Condition Special Needs Plan (C-SNP) through GoHealth!

Fill out the member information at the top of the form.

While Humana does not require you to sign the release authorizing your doctor to share patient information, your doctor’s office might.

Take the form with the top section completed to your doctor’s office. Your doctor’s office will complete and sign the bottom section before returning the form to Humana via the Availity provider portal, fax, or email. The office can also provide verbal verification by phone.

Provider portal: Availity
Fax: 877-889-9936
Email: VCC@humana.com
Verbal verification: 877-271-5229 (M-F 8:00 a.m. – 6:00 p.m. Eastern)

Humana must receive the Verification of Chronic Condition in fewer than 60 days after enrollment, or you will be disenrolled from your C-SNP.

Download Form

Fill in your doctor’s name and office phone number on the second page of the form. Fill in your name, Medicare number, and date of birth on the third page.

Fax or bring the entire form to your doctor’s office. Your doctor will complete the information about your chronic condition and sign.

Your doctor’s office can either fax or email the completed form to Zing Health or call a recorded line to verbally attest to your condition.

Verbal Recorded Line: 866-946-4458
Fax: 877-289-2295
Email: CSNPVerification@myzinghealth.com

Zing Health must receive verification within 30 days after the start of your coverage.

Download Form

Fill out the applicant section, including your name and either your Medicare number or your date of birth.

Give the form to your doctor’s office. Your doctor will complete the top section attesting to your chronic condition and sign.

Your doctor’s office may fax or mail the form to UnitedHealthcare.

UHC Provider Chronic Condition Verification line: 866-868-0615

Fax: 888-950-1170

Mail: United Healthcare
PO Box 30770
Salt Lake City, UT 84130-0770

Download Form

Fill out the patient information section.

Give the form to your doctor’s office to complete and sign.

Within five days, your doctor’s office should return the form by email or fax.

Elevance Health Anthem/Amerigroup Membership Department
Fax: 855-503-2573

Download Form

Fill out Section 1, including your name, date of birth, Medicare number, and phone number.

Give the form to your doctor’s office to complete and sign.

Your doctor’s office may return the form by fax or by secure email.

Fax: 866-756-5514 (Attention: Enrollment Department). Must include a coversheet with no personal health information.
Secure email: VCC@Aetna.com

Download Form

Fill and sign the top section, including your name, address, and Medicare number, as well as your doctor’s name and phone number.

Give the form to your doctor’s office to complete and sign.

Within five days, your doctor’s office should return the form by mail or fax.

Mail: CarePlus Health Plans
PO Box 14733
Lexington, KY 40513-4642
Fax: 1-855-819-8679

Download Form

Fill in your healthcare provider’s name and your personal information including your name, Medicare number, and date of birth.

Give the form to your doctor’s office to complete and sign.

Your doctor’s office may return the form by fax or verbally attest to your condition by phone.

Fax: 866-214-1992
Phone: 1-800-431-9007

Download Form

Fill in your personal information, including your name, address, date of birth, gender, Medicare number, and your new plan’s effective date, as well as your doctor’s name and phone number.

Give the form to your doctor’s office to complete and sign.

Within five days, your doctor’s office should return the form by fax.

Fax: 877-577-9042
Simply Healthcare Plans, Inc.
Attn: Enrollment Department
Email: GBDCSNP@anthem.com

Download Form