St. Luke's Direct Primary Care Enrollment Form

St. Luke's Direct Primary Care Enrollment Form

Please complete the form below to enroll in Direct Primary Care at no cost.
Name*

First NameLast Name
Email*
example@example.com
Mobile Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Gender*
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)

I would like to enroll my spouseI would like to enroll my child(ren)I will only enroll myself
Your Spouse's Name

First NameLast Name
Your Spouse's Date of Birth*

MonthDayYear
Date
Your Spouse's Gender*
How many children would you like to enroll?
Your First Child's Name

First NameLast Name
Your First Child's Date of Birth*

MonthDayYear
Date
Your First Child's Gender*
Your Second Child's Name

First NameLast Name
Your Second Child's Date of Birth*

MonthDayYear
Date
Your Second Child's Gender*
Your Third Child's Name

First NameLast Name
Your Third Child's Date of Birth*

MonthDayYear
Date
Your Third Child's Gender*
Your Fourth Child's Name

First NameLast Name
Your Fourth Child's Date of Birth*

MonthDayYear
Date
Your Fourth Child's Gender*
Your Fifth Child's Name

First NameLast Name
Your Fifth Child's Date of Birth*

MonthDayYear
Date
Your Fifth Child's Gender*
Your Sixth Child's Name

First NameLast Name
Your Sixth Child's Date of Birth*

MonthDayYear
Date
Your Sixth Child's Gender*
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.
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