Senior Partners Care Medical Program Application

MINNESOTA CITIZENS FEDERATION - NORTHEAST Senior Partners Care Medical Program Application 06/2013 If a question does not apply to you write "N/A". This form will be returned if information is missing. Name Date of Birth Spouse Date of Birth Address Apt. No. City If married, are you both applying for Senior Partners Care? State Zip Yes No Telephone# ( ) E-Mail: Emergency Contact Relationship ( ) ( ) HOME PHONE NUMBER WORK PHONE NUMBER MEDICARE INFORMATION Please refer to your red, white and blue Medicare card and complete the boxes below: SELF Health Insurance SOCIAL SECURITY ACT Name of Beneficiary Medicare claim number Is entitled to Hospitsal Insurance Medical Insurance Name of Beneficiary Medicare claim number Is entitled to Hospital Insurance Effective Date SPOUSE Health Insurance SOCIAL SECURITY ACT Effective Date Sex Sex Circle one: (Y) (N) Do you currently have health insurance besides Medicare? (Y) (N) Are you on Social Security Disability? (Y) (N) *Are you enrolled in a Medicare Advantage doctor & hospital coverage plan? (Y) (N) *Are you enrolled in Medicaid (Medical Assistance)? *NOTE: You cannot have Senior Partners Care and a Medicare Advantage Plan orl Medical Assistance at the same time. Social Security Spouse's Social Security Pension(s) Interest and Dividends Employment Income Other: Total Monthly Income = MONTHLY INCOME Medical Insurance PROGRAM REQUIREMENTS My annual income is: Single Person: Less than $22,980 Married Couple: Less than $31,020 My assets (excluding value of home, one car, and personal property) are: Single Person: Less than $47,100 Married Couple: Less than $47,100 LIQUID ASSETS (Y) (N) More than (1) property? (Y) (N) More than (1) vehicle? (Y) (N) Any boats, RVs, etc? $ Value of savings $ Value of stocks/bonds/cds $ Value of checking account $ $ $ Total Liquid Assets =

Name of Clinic you usually use Name of Hospital you usually use STATEMENT OF UNDERSTANDING We understand that the MINNESOTA CITIZENS FEDERATION - NORTHEAST and/or the participating care provider has the right to limit participation. Enrollment may be denied: A. If I/We fail to meet the income/asset guidelines for the program. B. If the information I/We furnish is found to be inaccurate. C. If I/We qualify for services under the Medical Assistance (MA) or (QMB) programs through the Department of Human Services. The SENIOR PARTNERS CARE PROGRAM does not provide a waiver for all health care expenses (ie: nursing home, ambulance) or any services not covered by Medicare for health care received from a health care provider (ie: specialist) who does not participate in the program. SENIOR PARTNERS CARE is NOT INSURANCE ; it is a unique community service program. It ONLY WORKS with the participating health care providers (see the separate list of these). We have been informed that I/We are not required by law to provide the personal, medical and financial information requested; however, failure to provide such information will result in I/We not qualifying for participation in this program. To assist with your application, please send proof of your income. This proof can include: 1. Photocopy of your most recent Social Security Benefit Statement (you MUST provide this); AND 2. Photocopies of bank and/or other financial statements; OR Photocopy of your most recent tax return. 3. If you live in subsidized housing, you can have the manager fill out a verification statement. Call the number listed below for the verification form if it is not attached. I/We understand that this information may be shared with health care providers. I/We have specified as the provider of choice and a facility to which I/We might be referred. I/We also understand that MnCF - NE will not share this information with any unauthorized persons. I/We certify that the information I/We have provided (including the financial information) is complete and accurate to the best of my/our knowledge. Applicant Spouse Date Are you a Minn. Citizens Federation - NE Member? Yes No Federation # Is your spouse a Minn. Citizens Federation - NE Member? Yes No Federation # Please return this form to: Minnesota Citizens Federation - Northeast 2110 W. First St. #102 Duluth, MN 55806 Tel: (218) 727-0207 Email: admin@citizensfed.org ACTION TAKEN FOR OFFICE USE ONLY Initial Approval/Disapproval Date Enrolled Denied Effective Reason Reason Citizens Federation signature Comments

Minnesota Citizens Federation - Northeast 06/2013 2110 West First Street Suite 102, Duluth MN 55806 (218) 727-0207 Senior Partners Care Program -- Application Letter Dear Citizens Federation - Northeast Member: Thank your for requesting information on our SENIOR PARTNERS CARE PROGRAM. This program is designed for people age 65 & up or disabled, on full Medicare coverage (both Medicare "A" and "B") with limited income, who have difficulty paying the portion of their medical bills that are not covered by Medicare and therefore, neglect their own health care. Eligibility for the program has an income limit which is 200% of the poverty line. The current income and liquid asset limit amounts are on the Application Form, and also in the brochure. The SENIOR PARTNERS CARE PROGRAM covers most kinds of medical care that you might need, including primary care doctors, specialists, and hospitals. For your primary care doctor, you can use any of the clinics or doctors on the enclosed list. You can use any of the participating specialists named on the enclosed list. NOTE: When you want to see one of the specialists on the Northland Medical Associates list, you must first call the Northland Medical Associates office at 726-5114 and they will set up the referral for you. This is very important because some of them reach their annual numerical limit and won't cover more patients under this program. The participating hospitals, which are listed on the second side of the enclosed list, will waive the Medicare Part A deductible for inpatient (overnight) care. Outpatient care coverage is complete, except that Community Memorial (Cloquet) has a numerical limit on how many people they will cover. Some of the participating physicians will accept Medicare's actual reimbursement to them as payment in full. However, other doctors waive Medicare's co-pays, but not Medicare's Part B $147 annual deductible. See the list of participating providers to see which clinics and doctors waive the $147 deductible and which ones do not. You will see that most, but not all, Duluth-area physicians are participating in this program. Anything that Medicare does not deem medically necessary (for example, cosmetic surgery) is not covered at all by this program. Treatments by any providers who are not on the enclosed list are not covered by this program. If you are unsure if a provider participates, call our office first! Referrals for some providers are limited, so there is a slight chance that you might not get the referral you ask for, especially towards the end of the year. But, in most cases your request will be fulfilled. If you receive any Medicare or insurance payments for any treatments, these must be turned over to the appropriate doctor or hospital. DO NOT send us any bills you receive. WE DO NOT PAY ANY BILLS -- This program is NOT an insurance policy. Certain providers - but not all - are agreeing to waive part of their charges. STEPS TO APPLY FOR THE PROGRAM 1. Please read the enclosed application and fill it out fully. 2. Return the application, signed and dated to the MN Citizens Federation - Northeast office, at the address at the top of this page. Include the documentation requested in the application. 3. Enclose your $35 annual Senior Partners Care (SPC) program fee, plus your $20 annual membership dues if you are joining or renewing your membership. The total is $55. 4. The Citizen Federation's Senior Partners Care Committee will then review your application and certify you for the program if you meet the criteria. 5. We will notify you by telephone or mail that you are enrolled and send you a SPC card identifying you as being on the program. We will forward your name to the participating providers. 6. When you go to a doctor or hospital tell them you are on the Citizen Federation's Senior Partners Care Program, and show them your Citizens Federation membership card. IMPORTANT: Use the enclosed list of our participating providers. Your SPC coverage is NOT useable with others. Thank you for your cooperation. If you have any questions, call our office at 727-0207.

Minnesota Citizens Federation - Northeast 2110 W. First St. Suite 102, Duluth, MN 55806 (218) 727-0207 Senior Partners Care Medical Program Statement for Manager of Subsidized Housing: According to our most recent records for the year, has an annual gross income of $ (Resident) Manager's Name Name of Building Date PERMISSION FOR RELEASE OF INFORMATION: I hereby authorize the release of the requested information to the Minnesota Citizens Federation - Northeast. Signature Date

Minnesota Citizens Federation - Northeast 06/2013 Senior Partners Care Dental Program - Participating Dentists List #1: These Dentists Will Take New Patients: Name Address Phone Bopp, David L. Chart, Kim Erickson, Timothy Johnson, Stephen D. Lake Superior Community Dental Clinic Langguth, Timothy R. Schneeweis, Jospeh Swanstrom, James R. 225 2nd St., Proctor 421 E. 4th St., Duluth 508 2nd Ave., Two Harbors 930 Medical Arts Bldg. 3600 Tower Ave., Superior WI 1111 Medical Arts Bldg. 2860 Piedmont Ave. 930 Medical Arts Bldg. 55810 55805 55616 55802 54880 55802 55811 55802 624-7002 727-1448 834-5616 727-5041 715-394-5411 722-0219 722-0823 727-5041 List #2 : These Dentist Only Honor Senior Partners Care for their Current Patients: Name Address Phone Balach, George Bussa, Michael Idziorek, Robert J. Sandelin, Rodney 5805 Grand Ave. 704 Medical Arts Bldg. 4891 Miller Trunk Hwy. #1 1428 Medical Arts Bldg. 55807 55802 55811 55805 624-4628 722-7271 722-7770 722-6919 Senior Partners Care Chiropractic Discount - Participating Chiropractors 20% Discount for All Members Associated Chiropractic Physicians, 1320 Kenwood Ave., Duluth 727-3686 (R. Torgrimson & A. Macioc) Bergquist Chiropractic, 1823 Belknap Ave., Superior WI 392-4078 Lake Superior Chiropractic Office, 2121 E. 5th St. Superior WI 398-6679 LeSavage, Graf, 1301 Miller Trunk Hwy, Duluth. 722-9300 Lukovsky Chiropractic Clinic, 5602 Grand Ave. 624-5751 and 4013 Woodland Ave., Duluth 728-0969 (D. Lukovsky, S. Lukovsky, R. Boisjoli) Setterquist Chiropractic, 216 Chestnut Ave., Carlton MN 384-4070 Tomanek, Therese, 2900 Piedmont Ave., Duluth 727-8228 20% Discount for Members Within SPC Guidelines; 15 % for Others: Lemieux, Judy, 2232 Berg Rd., Cloquet 879-3951 20% Discount on Visits and 50% Discount on X-rays for All Members: Ausmus, Regina, 1522 E. Superior St. 724-4077

Senior Partners Care Medical Program June 2013 Participating Medical Providers All doctors listed waive the 20% Medicare co-payment and any amounts over the "Approved" Medicare charge (referred to as Medi-Gap or balance billing). Some doctors waive the $147 annual Medicare deductible and some don't (as indicated). Important Note on the SMDC (Essentia) and St. Luke's systems: SMDC (Essentia): ALL of their doctors and facilities participate. But, they do NOT waive the $147 Medicare Part B annual deductible. (see below) St. Lukes: The hospital particpates, and most BUT NOT ALL of their doctors participate. The ones who participate DO waive the $147 Medicare Part B annual deductible. (see below) A. PRIMARY CARE DOCTORS I. Those that DO WAIVE the $147 Medicare annual deductible are: Lakeview Clinic 1010 4th St.; Two Harbors Duluth Family Practice Center 8th Av E & 4th St. Lake Superior Community Health Center 4325 Grand Ave. Lake Superior Community Health Center 3600 Tower Ave., Superior WI Lake Walk Surgery Center 1920 London Rd. Integrity House 1000 E. 1st St.; Suite 108 Raiter Clinic 417 Skyline Blvd., Cloquet St. Luke's Medical Clinics: Mount Royal Medical Center 1400 Woodland Ave. Denfeld Medical Center 4702 Grand Ave. Miller Creek Medical Clinic 4886 Miller Trunk Hwy Lester River Clinic 6351 E. Superior St. P.S. Rudie Medical Center 26 E. Superior St. Ste. 205 Bay Area Health Ctr., Silver Bay 50 Outer Drive Mariner Clinic, Superior, WI 109 N. 28th St. E. Chequamegon Clinic Ashland and Washburn, WI Laurentian Clinic, Virginia 901 9th St. Hibbing Family Medical Clinic 1124 E. 34th St. II. Those that DO NOT WAIVE the $147 Medicare annual deductible are: Duluth Clinic 4th Av E & 3rd St., and its satellites: Duluth Clinic - Hermantown Duluth Clinic - Lakeside Duluth Clinic - Superior Duluth Clinic - West 4855 W. Arrowhead Rd. 4621 E. Superior St. 3500 Tower Ave., Superior, WI 4325 Grand Ave. 834-7200 723-1112 722-1497 715-392-1955 728-0650 723-1100 879-1271 249-8800 249-6800 249-4600 249-4500 249-4300 226-4431 715-395-3900 715-82-6622 748-7480 362-7100 786-8364 786-3540 786-3550 395-5454 786-3500 AND: Other Duluth Clinics in Minnesota: Aurora, Babbitt, Chisholm, Deer River, Ely, Hibbing, International Falls, Remer, and Virginia; and in Wisconsin: Ashland, Hayward, Spooner; and Ironwood, Michigan. ALSO: Duluth Internal Medicine Associates 220 Medical Arts Bldg 727-8585 Drs. Albright, Apostolou, Harwood, Howard, Huska, & Sproat Page 1 of 3

Senior Partners Care B. SPECIALISTS B. SPECIALISTS I. Specialists who WAIVE the $147 annual deductible: These St. Luke's Clinics: Participating Medical Providers - continued: Oncology Hematology Associates: Drs. Baker, Medis, Repka, & Foltz 1001 E. Superior St. Duluth Cardiology Associates: Drs. Bernard & Lee 1001 E. Superior St. Northland Dermatology: Dr. Holm 920 E. 1st St. Allergy & Immunology: Dr. Monson 920 E. 1st St. Duluth Neurological Institute: Drs. Klironomos & Watson 920 E. 1st. St. Endocrinology Associates: Drs. Sjoberg & Aipolanai 1011 E. 1st St. Medical & Surgical Dermatology: Drs. Evanson, Holm, & Bucholz 920 E. 1st St. Northland Rehab Associates: Drs. Harrison, Wallerstein, & Weinman 1011 E. 1st St. Rheumatology Associates: Drs. Hadley, Moore, & Kahn 1000 E. 1st St. Ophthamology Associates 800 Medical Arts Bldg. II. Specialists who DO NOT WAIVE the $147 annual deductible: 1) All Duluth Clinic (Essentia) specialists 4th Av E & 3rd St., Duluth 722-8364 plus at all their satellite clinics 2) Dr. Maryland; ophthalmologist 509 Medical Arts Bldg. 722-5871 3) Drs. C. Moen, S. Warren, J. Sauer, T. Naftzger & R. Blaha; orthopedics 3500 Tower Av, Superior, WI395-2220 249-3081 249-3057 249-7930 249-7920 249-2450 249-7890 249-7930 249-6980 249-6960 722-6655 4) Specialists who are part of the Northland Medical Assoc. of Duluth. THEY ARE LISTED BELOW. NOTE: To get a referral to one of these Northland Medical Associates specialists, or, if you have one as a primary care physician, BEFORE you go to see the doctor, you must call the Northland Medical Associates office at 722-9418 and let them know you are on Senior Partners Care. Duluth Internal Medicine Associates 220 Medical Arts Bldg. Drs. Albright, Apostolou, Harwood, Howard, Huska, & Sproat Northland Surgical Associates Northland Medical Center (1000 E. 1st St.) Drs. Barbee & Nevonen Dr. Thomas Holm - Dermatologist Northland Medical Center South Northland Ear, Nose & Throat Associates 920 E. 1st St. Suite 301 Drs. Choquette & Freeman and, Audiology Dept.: Dr. Hougas, & Sharon Johnson MA.CCCA Laboratory Medicine Specialists 915 E. 1st St., Duluth Drs. Easlop, Lundeen, Steinhauer, Baerkartch, Warren, & Zionis Northland Gastroenterology & Surgery 1420 London Rd. Dr. McKee SPECIAL NOTE: The Mayo Clinic and its hospitals in Rochester, Minnesota DO NOT participate in Senior Partners Care. However, some Twin Cities hospitals DO participate. If you need special treatment not available in Duluth, call our office at 727-0207 to see about making arrangements about care in the Twin Cities. You MUST call us in ADVANCE. Page 2 of 3

Senior Partners Care C. HOSPITALS Participating Medical Providers - continued: All of the hospitals listed waive the $1,184 Medicare Part A in-patient deductible. Other services vary from hospital to hospital. See below. St. Mary's Hospital (Essentia), 407 E 3rd St., Duluth, 786-4000. Services provided: all Part B co-pays for outpatient services waived and 20% discount on home care services. St. Luke's Hospital, 915 E 1st St., Duluth, 249-5555. Services provided: All Part B co-pays and the annual Medicare deductible for outpatient services waived, including Urgent Care. 10% discount on home care services. Miller-Dwan Medical Center (Essentia), 502 E 2nd St., Duluth, 727-8762. Services provided: Services provided: all Part B co-pays for outpatient services waived. Community Memorial Hospital, Skyline Blvd, Cloquet 879-4641. Services provided: All Part B co-pays and the annual Medicare deductible for outpatient services waived. Lake View Memorial Hospital, 325 11th Ave., Two Harbors, 834-7300. Services provided: All Part B co-pays and the annual Medicare deductible for outpatient services waived. Does not include long term care or swing bed. St. Mary's Hospital of Superior (Essentia), 3500 Tower Ave., Superior, WI, 395-5400. Services provided: All part B co-pays for outpatient services waived. White Community Hospital (Essentia), 5211 Highway 110, Aurora, MN, 229-2211. Services provided: All part B co-pays for outpatient services waived. NOTE: Some Twin Cities hospitals also participate in Senior Partners Care. Additional application materials are required in advance. Call 727-0207 for more information. D. SPECIAL SERVICE PROVIDERS These providers generally waive the co-pays for items covered by Medicare, and give a 20% discount on other items. Apria Healthcare, 701 N. 6th Ave. E., Duluth Duluth Diabetes Center, 400 E. 2nd St., Duluth Duluth IV Center, 420 E. 1st St., Duluth Duluth MRI, 404 E. 4th St., Duluth Duluth Radiologists P.A., 824 Medical Arts Building, Duluth 724-3233 786-3424 786-3001 786-2363 722-3185 Freedom Respiratory Solutions (Provider Care), 831 E. 2nd St., Duluth 725-0000 and 392-3875 Gallery Optical, 324 W. Superior St., Duluth (20% discount on eyeglasses) 722-1477 Hearing Associates, 4105 Matterhorn Drive, Duluth Hearing Express, 25 N. 12th Ave. E., Suite E, Duluth (20% hearing aid discount) 723-8208 724-3477 Home Care Oxygen & Medical Equipment, 810 E. 4th St., Duluth In Motion Therapy, 2711 W. Superior St. Suite 209, Duluth J. Marco Beltone Hearing Service, 324 W. Superior St., Duluth (20% hearing aid discount) Lake Superior Medical Equipment Inc., 522 E. 4th St., Duluth MD Anesthesia Services, Ltd., 915 E. 1st St., Duluth Midwest Medical Equipment & Supplies, 4418 Haines Rd, Duluth Northern Lights Counseling Center, 101 W. Superior St., Duluth Polinsky Medical Rehabilitation Center, 530 E. 2nd St., Duluth Radiological Associates of Duluth, Ltd., 925 E. Superior St., #109, Duluth Schamber Alternative Medicine, 2701 W. Superior St. Suite 103, Duluth 722-2222 727-1180 395-0384 727-0600 726-5352 722-3420 740-3026 786-5360 722-3700 727-8787 For more information: MN Citizens Federation - Northeast, 2110 W. First St. #102, Duluth MN 55802 Phone: (218) 727-0207 Email: admin@citizensfed.org Page 3 of 3 June 2013