Chronic Condition Verification Form

Release of Information
By joining either the Sonder Diabetes Wellness Plan (C-SNP H1748003) or the Sonder Heart Healthy Plan (C-SNP H1748004), I acknowledge that I have one or more of the following conditions:
Diabetes Condition(Required)
(Care Provider/Specialist) to confirm my chronic condition and disclose my medical records to Sonder Health Plans. This authorization shall be effective until I am no longer enrolled in Sonder Health Plans.

Application Use and Disclosure Authorization

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If you are the authorized representative of the applicant, provide the following information:
I understand that my printed name (or the printed name of the person legally authorized to act on my behalf) on this C-SNP Verification Form (“Form”) means that I have read and understand the contents of this Form. If the Form has the printed name of an authorized representative, the printed name certifies that: 1) This person is authorized under State law to complete this Form, and 2) Documentation of this authority is available upon request by Medicare.

Provider Confirmation of Chronic Condition.

(Care Provider/Specialist), hereby certify that
(Applicant) has the following health condition(s):
Diabetes Condition(Required)
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Fax this completed form to: 1 (888) 891-0019

Mail this form to:

Sonder Health Plans

6190 Powers Ferry Road, Suite 320, Atlanta, GA 30339
If you have any questions, please call: 1 (888) 428-4440, TTY 711, 7 days a week, 8 am - 8 pm.
Sonder Health Plans, Inc. is an HMO with a Medicare contract.
Enrollment in Sonder Health Plans, Inc. depends on contract renewal.