Member Facing 2023 MAPD Health Risk Assessment (HRA) SFMC

Contact Information

Please complete the below form to complete the Health Risk Assessment (HRA).

SubmissionDate *This question is required.

First Name *This question is required.

Last Name *This question is required.

Date of birth *This question is required.

1. Sex

Phone number *This question is required. Format: ###-###-####

2. Member email *This question is required. Providing an email address authorizes Priority Health to contact you via email. Your email address will be handled consistent with our Privacy Policy. This question requires a valid email address.

Medicare number (XXX-XXX-XXXX) *This question is required. This number can be found on your red, white, and blue Medicare card.

3. Address *This question is required.

4. City *This question is required.

5. State *This question is required.

6. Zip Code *This question is required.

7. Do you have a mailing address that is different than your permanent residence address? *This question is required.

Other Address *This question is required.

Other City *This question is required.

Other State *This question is required.

Other Zip Code *This question is required.

8. Requested Effective Date *This question is required. Please select your proposed effective date of Coverage This question requires a valid date format of MM/DD/YYYY.

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