<Date>

<Member Name><Address><City, State, ZIP>

Dear <Member Name>:

Enclosed you will find the Comprehensive Care Plan that was developed with you on <date>.

Please review this Care Plan. If you find it acceptable, please sign it and return the signature page in the enclosed self-addressed, stamped envelope.

Please contact <name>, your care coordinator at <phone number> if you: Do not agree with the Care Plan. Have any questions about the Care Plan. Have experienced a change in your service needs.

TTY machine users please call the Minnesota Relay at 711 or 1-877-627-3848 (speech-to-speech relay service).

Thank you,

<Care Coordinator Name><Care Coordinator Job Title><County or Agency Name><Phone Number><E-mail Address>

UCare Connect + Medicare (HMO SNP) is a health plan that contracts with both Medicare and the Minnesota Medical Assistance (Medicaid) program to provide benefits of both programs to enrollees. Enrollment in UCare Connect + Medicare depends on contract renewal.

MSC+ SNBC H5937 H2456_011317_1 DHS Approved (01252017) U2848D (11/18)

500 Stinson Blvd NE, Minneapolis, MN 55413 | 612-676-6500 | fax 612-676-6501 | ucare.org

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