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.

Insurance 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 via text message?

I agree to receive texts.I do not want to receive texts.

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 providing your information and submitting this form, you agree that AMC Health may contact you by call, text, or email, which may include automated messages, at the email address and phone number you provided regarding AMC Health’s health programs, services, or enrollment. Your consent is not required as a condition of purchase or receiving services from AMC Health. You may opt out at any time by replying STOP to any text message or following the unsubscribe instructions in our emails. Standard message and data rates may apply. See our Privacy Policy for details. See our Privacy Policy.