Elevate Medicare Advantage Flex Card Self-Attestation

To qualify for the Healthy Food* benefit, you must have one or more of the chronic conditions listed below.

Autoimmune disorders
Cancer
Cardiovascular disorders
Chronic alcohol and other drug dependency
Chronic and disabling mental health conditions
Chronic heart failure
Chronic lung disorders
Dementia
Diabetes
End-stage liver disease
End-stage renal disease (ESRD)
HIV/AIDS
Neurologic disorders
Severe hematologic disorders
Stroke

By submitting this form, you are confirming you have one or more of these conditions and qualify for this benefit.

First Name *

Last Name *

Member ID (found on your member ID Card)

Date of Birth *

I qualify *

DOWNLOAD FORM DATA (PRIOR TO SUBMISSION):

If you would like to download the data you have entered in this form, click on the 'Download Form Data' button below. A CSV file that contains the data you are providing in this form will be downloaded to your computer. You need to click the 'Download Form Data' button after you have completed the form but before you click on the 'Submit Form' button.

Disclaimer: Your attestation is valid for up to 12-months from this submission. During this time, it is important to see your doctor so they can diagnosis your condition(s).

This benefit is part of the Special Supplemental Benefit for the Chronically Ill. Not all members qualify.

SUBMIT FORM:

You must complete all required fields prior to submission. To ensure files and data are successfully submitted, do not close this window until you see a confirmation page.

*Field is required

H5608_FoodAttestation_C