General Enrollment Form

HIPAA-sensitive enrollment information Please complete this form only on a private device and a secure connection. Prime Care will use the information for enrollment review and care coordination.

Personal Information

Tell us who the enrollment is for and how the participant prefers to be identified.

First Name *

Middle Name

Last Name *

Preferred Name / Nickname

Date of Birth *

Gender *

Male Female Non-binary Prefer not to say

Marital Status

Social Security Number

Race / Ethnicity

Preferred Language

Contact Information

Provide the best address and phone details for enrollment follow-up.

Street Address *

City *

State *

ZIP Code *

Home Phone

Cell Phone *

Work Phone

Email Address

Preferred Contact Method *

Home Phone Cell Phone Work Phone Email

OK to leave voicemail?

Yes No

Emergency Contact

Share one trusted contact we may reach if urgent support is needed.

Emergency Contact Name *

Relationship *

Emergency Contact Phone *

Insurance Information

Enter insurance details exactly as they appear on the member card when possible.

Primary Insurance Company *

Policy / Member ID *

Group Number

Insurance Phone Number

Policy Holder Name *

Policy Holder Date of Birth

Relationship to Patient *

Self Spouse Parent Other

Secondary Insurance?

Yes No

Secondary Insurance Company

Secondary Policy / Member ID

Consent & Signature

Review the acknowledgements and sign with the participant's full legal name.

Required Acknowledgements

I acknowledge receipt of the Notice of Privacy Practices I consent to evaluation and treatment I agree to pay for services rendered

Patient Signature *

Typing the full legal name serves as an electronic signature.

Date *

Relationship (if signing for minor)

Contact Info

Patient Portal

General Enrollment Form

Personal Information

Contact Information

Emergency Contact

Insurance Information

Medical History

Consent & Signature