Two ways to Enroll

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