Member ID Validation

For completion by the Beneficiary, or in the presence of the Beneficiary with support, as needed.

Enter your Medicare Beneficiary Identifier to see if you are in our system.

Note: Medicare Beneficiary Identifiers must be 11 characters. The 1st, 4th, 7th, 10th, and 11th characters will always be numbers. The 2nd, 5th, 8th, and 9th characters will always be upper-case letters, except for S, L, O, I, B, and Z. The 3rd and 6th characters will be letters or numbers.

Beneficiary

Personal Information

Medicare Beneficiary ID*

First Name*

Last Name*

Contact Information

Phone Number

Address Information

Address*

City*

State*

ZIP*

Provider Information

If your provider practice is in a different location than the state where you reside, please select the state associated with your provider’s practice address. If they are the same, no action is needed.

Provider State*

Provider*

Please Select

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Group*

NOTE: If the names listed above and in the letter are incorrect do not sign this form. If you would like to receive a new form with a different doctor, other healthcare professional, or practice listed, please call CVS Accountable Care at 1-866-204-2273 to request a new form.

Signature*

Clear Signature

NOTE: Completing and returning this form is voluntary. It won't affect your Medicare benefits.

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