CMS forms entitled, “Confirmation of Main Doctor or Other healthcare Professional Form”  (click here to print form)


SAMC Patients,

CMS forms entitled, “Confirmation of Main Doctor or Other Healthcare Professional Form”, were sent out to Medicare patients by Asaar Medical by mail. Medicare has started an initiative where health care providers who share a common set of goals aimed at improving patient care can work together more effectively. This initiative brings together healthcare professionals in an Accountable Care
Organization (ACO).

South Austin Medical Clinic is voluntarily taking part in this new initiative by partnering with Asaar Medical because we think it will help us provide better quality care for our patients.

You can use this form to confirm that our practice is the main doctor you see or the main place that you go to for routine care to help determine if Asaar Medical should help coordinate your care. Alternatively, instead of returning this form, you can also log into and select your main doctor or other health care professional.

Your benefits will NOT change and you can choose any doctor, other health care professional, or hospital. Whether you choose to complete this form or not, you will remain eligible to receive the same Medicare benefits and you still have the right to use any doctor, other health care professional, or hospital that accepts Medicare at any time. Completing this form is your choice.

For additional information, you may visit:


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ACO Website: