• St. Luke's Direct Primary Care Enrollment Form

    Please complete the form below to enroll in Direct Primary Care at no cost.
  • Format: (000) 000-0000.
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • I would like to enroll my dependents (please note, your dependents must be included on your CHL Systems medical plan to enroll in Direct Primary Care)
  • Your Spouse's Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Your First Child's Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Your Second Child's Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Your Third Child's Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Your Fourth Child's Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Your Fifth Child's Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Your Sixth Child's Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • I authorize St. Luke's Direct Primary Care to send email or text which may include unencrypted protected health information. I understand data rates may apply, and to reply STOP to opt out. 


    Providing St. Luke's with authorization to email and text you will allow St. Luke's Direct Primary Care to exchange information with you more efficiently and will benefit you as a member. At the same time, St. Luke's recognizes that email and text messaging are not a completely secure means of communication.


    You are not required to authorize the use of email and text messages and a decision to not authorize electronic communication will not affect your health care in any way.


    St. Luke's has taken considerable effort to protect the personal health information of its members, and recommends that all members provide them with this authorization so that we can more efficiently communicate with them.

  • Should be Empty: