General Enrollment Form

Prime Care Health Solutions

General Enrollment Form

Prime Care Health Solutions | 2100 HWY 360 N, Grand Prairie, TX 75050 | 214-613-2019

Date *

Enrollment ID

Personal Information

First Name *

Middle Name

Last Name *

Date of Birth *

Gender *

SSN (Last 4 digits)

Marital Status

Height *

ft in

Weight (lbs) *

Contact Information

Phone *

Email *

Address *

Insurance Information

Medical Insurance Provider

Policy/Group Number

Pharmacy Insurance Provider

RX Bin / PCN

Type of Service Required *

Medical History / Notes

Current Medications

Allergies

Additional Notes

Consent & Signature

I consent to receive services from Prime Care Health Solutions and acknowledge that my information will be handled in accordance with HIPAA regulations. *

Patient Signature (Type Full Name) *

Date *

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