Download the Enrollment form below

(This enrollment form can be downloaded, electronically filled out, signed and uploaded or emailed directly to Crown Health or this form can be printed on your home/office computer, filled out, signed, then faxed or mailed to Crown Health.)

ALL of the following information MUST be provided in order for us to complete the enrollment process

  • Make sure the patient, POA (Power Of Attorney) or legal guardian completes all fields and  signs pages 3 and 4.
  • Copy of Insurance card(s)
  • Current Medication List
  • POA/Guardianship documents

You may mail or fax this information to:
Crown Health
23745 225th Way S.E. Ste 201
Maple Valley, WA  98038
Fax  (206) 694-2291

Please note:

  •  The enrollment process generally takes 2 weeks start to finish• You will continue with your current primary care provider until seen by Crown Health
  • We cannot order lab work or fill medications for you until we have seen you
  • Hospice: Crown Health does not accept new patients that are on hospice or anticipate being on hospice within the next 30 days. Patient should remain with their current provider for the best continuity of care.
  • If you have any questions, please feel free to contact our office at: 888-674-5871 ext. 250 or by email rachaelb@crownhealthus.com

Electronic form instructions:

For your convenience we have provided an electronic enrollment form that can be uploaded directly to us or sent via email.

  1. Download the electronic Enrollment form by clicking the link below.
  2. When the PDF document opens in your browser, select file in the upper left corner of your browser and select “save file as” to save the form to your desktop. See image here
  3. Open the form and type your information into the fields of the PDF.
  4. Re-save the document to your desktop.

Once you have completely filled out the PDF form and re-saved it with your information, select the upload link provided below.
Locate your enrollment form on your desktop and select send. You may also email the completed enrollment form.

Please contact us if you have questions regarding the enrollment form at 888-674-5871 ext. 250 or by email rachaelb@crownhealthus.com

            pdf_icon  Click here to download the enrollment form
          
Upload  For your convenience, you can upload your completed Enrollment Form here