SecureCare HMO Enrollment

By joining this Medicare health plan, I acknowledge that SecureCare HMO will release my information to Medicare and other plans as is necessary for treatment, payment and healthcare operations. I also acknowledge that SecureCare HMO will release my information including my prescription drug event data to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan.


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