Membership Inquiry

Membership Inquiry

Thank you for your interest in joining membership at Assurance Healthcare & Counseling Center. Please complete the questions below in order to begin the membership process.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
What day would you prefer to start membership?

MonthDayYear
Date
I hope to register...*
How old is the primary account holder?
Have you been a member with Assurance Healthcare & Counseling Center in the past?*

YesNoNot sure
What health benefits do you currently have? Check all that apply

I have nothing: I'm cash-payI have insurance through my employerI pay for my own private health insuranceI'm part of a health sharing ministry / organizationI'm on Medicaid (Apple Health, Coordinated Care, etc.)I'm on MedicareOther
Do you expect the above status in health coverage to change in the near future? Leave blank if no - enter date if true.

MonthDayYear
Date
Assurance Healthcare & Counseling Center makes a significant investment and commitment to the healthcare of our members - especially when first establishing with us. Therefore, we ask all new members to commit to membership for a consecutive 6-month period when first joining. This is not an up-front payment of 6-months, just a commitment to remain with use for a consecutive 6-months. After the initial 6-month commitment, the membership commitment is month-to-month.
According to the above paragraph, are you ready and willing to commit to an initial membership of 6 months once a waitlist spot opens up?*
To provide safe, high-quality care, we ask prospective members about their current medications. Direct Primary Care is a unique model, and certain medications or conditions may require specialized monitoring that is outside the scope of our clinic. This information helps us ensure we can meet your healthcare needs effectively. Please list all medications you are currently taking:*
Is there anything specific you are hoping to have addressed with a membership with us? Or any other questions or comments?
By clicking the submit button below, you agree to have the above information sent securely via this HIPAA compliant form to another third-party application managed by Assurance Healthcare & Counseling Center where private data is securely stored. Any identifying PHI (protected health information) will not be transmitted via email or any insecure format.
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