New User Enrollment Form

Name

First NameLast Name

Date of Birth

The day you were born.

Health Insurance

The name of your health insurance provider.

ID Number

This can be found on your insurance card.

Phone Number

The best number to call you.

E-mail

example@example.com

Would you like to receive updates on your enrollment via text?

I agree to receive texts related to the program.I do not want to receive texts related to the program.

What day of the week is best to contact you?

What is the best time to contact you?

How did you hear about us?

AMC Health values your privacy, and any information submitted through this HIPAA-compliant form is solely for AMC Health and your insurance company. Your data will never be shared or sold to third parties. We take extra steps to ensure your sensitive information is safe through our HITRUST certification.

By submitting this form, you agree to receive program communications via email or text from AMC Health. You can opt out anytime. Standard message and data rates may apply. See our Privacy Policy.