Medicare Advantage Plan Network Termination Patient Reporting Form

Please provide as much information as you can regarding your physician's termination from a Medicare Advantage network. If needed, you can fill out the form multiple times.

Contact Information

Full name

City, State, ZIP*

Email address

Phone number

Can we contact you directly if more information is needed?

Yes
No

Medicare Advantage Plan Information

Plan name

Insurance company name

City/State

Type of Medicare Advantage Plan (check all that apply)

Preferred Provider Organization (PPO)
Health Maintenance Organization (HMO)
Provider Sponsored Organization (PSO)
Medicare Savings Account (MSA)
Private Fee-for-Service (PFFS)
Religious Fraternal Benefits (RFB)

Name of physician dropped from plan

Did you receive a notification letter from the insurance company?

Yes
No

Date learned your doctor was dropped: mm/dd/yy

Were you given a referral to a retina specialist?

Yes
No

Were you able to schedule a timely visit?

Yes
No

Is traveling to this retina specialist more, less or equally convenient?

More
Less
Equal

Please provide any other information you think may be helpful:

Are you considering changing health plans based on your physician being terminated from the plan?

Yes
No

Did you issue a complaint with the Centers for Medicare and Medicaid Services (CMS)? Their contact information is 1-800-MEDICARE.

Yes
No


: Cancel

American Society of Retina Specialists 20 North Wacker Drive, Suite 2030, Chicago, Illinois 60606 (312) 578-8760 phone info@asrs.org