Heritage Family Care

470 Bank Street

New London, CT 06320

12 November 2009
Dear Oxford and United Healthcare Subscriber:

Effective 06 March 2010, Heritage Family Care’s contract with Oxford Health Plans will expire.
Effective 06 May 2010, Heritage Family Care’s contract with United Healthcare will expire. Dr.
Applegate will not be renewing her association with either Oxford or United Healthcare. Heritage
Family Care is giving you as much notice as possible to allow you to explore your options.

For patients wishing to stay with Dr. Applegate, some of the following options are available to
you:

• Choose another insurance company (for most employees this is an annual option, check
with your company’s HR department for details);

• Utilize Dr. Applegate as an “Out of Network Provider” (check with your insurance carrier
to see if you have Out of Network coverage, and what you must do to activate that benefit);

• Self pay for your visits with Dr. Applegate.

For us to better serve you, we are requesting that you notify the office of your decision by
returning the bottom portion of this letter as soon as possible.

Thank you,
Heritage Family Care

_________________________________________________________

Please check one (sign and return):

 I plan on finding a new primary care doctor.

 I plan on changing my insurance company, and continuing to see Dr. Applegate.

 I plan on staying with my present insurance carrier, but continuing to see Dr. Applegate
(I understand that I will be required to pay for my visits to Heritage Family Care at the time of service,
regardless of my reimbursement status with my insurance carrier).

Print Name ___________________________________________

Signature _____________________________________________ Date______________