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ACCESS Model Sign-Up
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Check Eligibility Status using Reference Number
Patient Demographics
First Name
*
First Name is required.
Last Name
*
Last Name is required.
Gender Assigned At Birth
*
Select...
Male
Female
Other
Gender is required.
Date Of Birth
*
Date Of Birth is required.
Medicare Beneficiary # (MBI)
*
Medicare Beneficiary # is required.
Cell Phone #
At least one phone number (Cell or Home) is required.
Home Phone #
At least one phone number (Cell or Home) is required.
Address
*
Patient Address is required.
State
*
Select State
State is required.
Patient City
*
City is required.
Zip Code
*
Zip Code is required.
Pharmacy State
*
Select State
Pharmacy State is required.
Remember my Pharmacy State & Location for future visits
Assigned Pharmacy Location
*
Pharmacy Location is required.
Family Doctor Information
Search
I don't currently have a family doctor.
First Name
*
First Name is required.
Last Name
*
Last Name is required.
NPI Number
*
NPI Number is required.
Gender
*
Select...
Male
Female
Other
Gender is required.
Office Contact No.
*
Office Contact No is required.
Fax
Fax is required.
Authorized Person Details
I don't have an authorized person.
First Name
*
First Name is required.
Last Name
*
Last Name is required.
Gender
*
Select...
Male
Female
Other
Gender is required.
Phone
*
Phone is required.
Relationship
*
Select...
Spouse
Parent
Child
Sibling
Legal Guardian
Other
Relationship is required.
Consent Completed By
First Name
*
Clinician First Name is required.
Last Name
*
Clinician Last Name is required.
Patient Verbal Consent
On behalf of our community pharmacy and our clinical partner, GamePlan Medical, we'd like to welcome you to The Advancing Chronic Care with Effective, Scalable Solutions or ACCESS Model. This new program sponsored by Medicare, gives you a personalized plan and support for staying healthy, sharp, strong and independent at home to enhance your medications. Participation in the ACCESS Model is completely voluntary and is covered by straight Medicare with no out-of-pocket costs or copayment. To better support you at home, our team may contact you from time to time via telephone, text messaging, and AI-assisted coaching. To better coordinate your care, we may share information with members of your care team, such as your family doctor or other medical specialists. To check your eligibility for the ACCESS Model, we will securely submit this consent and other information to Medicare. Based on this submission, we will notify you of your eligibility. A small group of participants may be assigned to a comparison or control group for research purposes. If Medicare assigns you to a control group, you will be ineligible to participate in ACCESS for up to 12 months. This will not affect any of your Medicare benefits or healthcare coverage. Once enrolled in ACCESS, you may voluntarily end your participation at any time after an initial 90-day period. After this 90-day period you may choose to participate with any other ACCESS provider if eligible. Thank you for your interest in the ACCESS Model. Is it OK if we sign you up?
Is it OK if we sign you up?
*
Yes, sign up
No, decline
Yes but not Eligible
Patient consent selection is required.
Track Validation Process
Exclusion
Clinician Supervision Required:
"By selecting a track you attest that the patient is both on medication for the condition and was told by their medical provider that they have the specific condition."
⚠️ Maximum of 3 tracks/conditions can be selected across all categories.
⚠️ Track 1 and Track 2 cannot be selected together. Please deselect one to proceed.
⚠️ For Track 1, Please select High blood pressure (I10) or at least two other eligible conditions [Dyslipidemia (E78.00), Obesity (E66.9), Prediabetes (R73.03)] to continue.
You can select a maximum of 3 items across all tracks.
SUBMIT & ENROLL PATIENT
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Check Eligibility Status using Reference Number
Success!
Patient submitted to registry. Automated CMS eligibility check pipeline active.
Search NPI
Please enter at least one search criterion. State cannot be searched alone. When selecting a State, also enter City, NPI Number, First Name, or Last Name.
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First Name
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