Patient Portal

Application

Welcome. This is where you register to be a member. You may also register your spouse. Children, ages 18 to 26, are provided free membership when both parents are enrolled.

Member Information

 

 

Spouse Information

 

 

Child Information No. 1

 

 

Child Information No. 2

 

 

Child Information No. 3

 

Payment Information

 

Click on "SUBMIT" button below to submit your membership request. Because enrollment is capped to a limited number of patients, your membership cannot be guaranteed. Applications for enrollment will be time stamped. Your check will not be deposited nor charge card charged until your membership is accepted. You will be notified within 30 days.