Prime Care Enrollment

Refer a Patient

Provider and partner referral form for Prime Care program review and follow-up.

Secure enrollment form Please complete this form on a private device. Medical and enrollment information may be HIPAA-sensitive.

Referral Source

Tell us who is sending the referral and how we can follow up.

Referrer Name *

Organization

Referrer Phone *

Referrer Email *

Referral Type *

Provide the patient details needed for Prime Care outreach.

Patient First Name *

Patient Last Name *

Patient Date of Birth

Patient Phone *

Patient Email

Patient ZIP Code

Share clinical or program details that may help us triage the referral.

Reason for Referral *

Known Conditions

Diabetes Hypertension Heart Disease Asthma Depression/Anxiety Other

The patient has given permission to be contacted by Prime Care *