United Physicians Care Management

Your name*

Date of Birth of Patient*

Policy Type
BCBSMBCNPriority Health

Your telephone number*

Your email*

The name of the Patient’s Primary Care Physician*

Care Manager support types …
Registered NursePharmacistRegistered DietitianSocial WorkerBehavioral Health Social WorkerCommunity Health Worker

The support you are interested in …
EducationSkill BuildingGoal setting, coaching and motivationResource connectionCare coordinationAdvocacyOther

Please feel free to give us more details of what your goals or concerns are.

United Physician’s Notice of Privacy Practices (NPP)*
I acknowledge that I have received United Physician's NPP.

*required

The information you have submitted will be securely sent to the United Physicians’ Care Management team. This along with any other personal information collected during your time with the United Physicians’ Care Management team, will be governed by the United Physicians Notice of Privacy Practices (NPP). This notice explains your rights and United Physicians’ efforts to protect your information as well as permitted uses of your information.