By submitting this questionnaire, I acknowledge and understand the following; I acknowledge that the information completed on this form is accurate to the best of my knowledge. I understand that my participation in this program is voluntary. I also understand that KelseyCare Advantage and any representatives may share this information with appropriate members of the KelseyCare Advantage Plan Network, which I have selected to provide for my health care needs. This may include my Primary Care Physician, Specialists and other health care providers to whom I may be referred, and hospital representatives. I understand that KelseyCare Advantage will treat this information in a confidential manner, and will not share it with anyone unrelated to my health care needs, and that this information will not impact my health insurance coverage.