Altrix Direct Enrollment Form To enroll in our ALTRIX DIRECT program: 1. Download an Enrollment Form pdf here and email the completed form to office@altrixpc.com – or – 2. complete and submit the form below:Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneCell PhonePreferred Email address(Required) Spouse / Partner / Significant Other covered?YesNoSpouse / Partner / Significant Other's Name First Last Date of Birth MM slash DD slash YYYY Home PhoneWork PhoneCell PhoneEmail Number of Children included with Coverage PlanPlease enter a number from 0 to 5.Child 1 First Name Last Name Date of Birth MM slash DD slash YYYY Child 2 First Name Last Name Date of Birth MM slash DD slash YYYY Child 3 First Name Last Name Date of Birth MM slash DD slash YYYY Child 4 First Name Last Name Date of Birth MM slash DD slash YYYY Child 5 First Name Last Name Date of Birth MM slash DD slash YYYY Do you have Insurance coverage?(Required)YesNoName of Insurance Company Do you have Medicare?(Required)YesNoDo you have Medicaid(Required)YesNoPreferred Payment Method(Required)YearlyMonthlyCredit Card Type(Required)MastercardVISAOtherType of Card(Required) Cardholder Name(Required) First Last Card Number(Required) Expiration Date(Required) Security Code(Required) Billing Address same as above?(Required)YesNoBilling Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Employer Consent(Required) I agree to the terms and conditions below:Terms and conditions of Altrix Direct membership agreement.Date(Required) MM slash DD slash YYYY Patient represents and acknowledges that neither the patient nor any family member enrolled in ALTRIX DIRECT are enrolled in or covered by Medicare, Medicaid, or any private healthcare plan offering primary care benefits.
