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Two ways to Enroll

Online Enrollment

Choose ONE of the appropriate online forms below, complete all information and upload attachments
  • If Patient is providing their own consent for treatment:

Enroll Online - Patient Consent

  • If a POA/Guardian is consenting on behalf of the Patient: 

Enroll Online - POA/Guardian Consent


Download and Complete

Step 1: Complete and return Enrollment Packet


Step 2: Gather all required documentation

All of the following must be provided in order for us to complete the enrollment and schedule a visit:

  1. Enrollment packet – filled out completely (hand write or type)
  2. Consent signatures – Patient, POA (Power of Attorney) or Legal Guardian signs all the required fields of this enrollment packet
  3. Copy of Insurance Card(s)
  4. Current Medication List – Request the most up to date list from patient's pharmacy
  5. POA/Guardianship documents
Step 3: Send all documents to Crown Health
Please Note:
  • The enrollment process generally takes a few days but can be up to 14 business days; once complete, the patient will be scheduled to be seen at the provider's next visit to the community or residential area.
  • The patient will continue with their current primary care provider until seen by Crown Health.

Please contact us if you have questions regarding enrollments at 888-674-5871 or by email enrollment@crownhealthus.com.