Alive & Well Clinic Member Enrollment Form

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Your Name* This field is required.

First Name

Last Name

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Your preferred name (only if you have one):If you go by your first name, please leave this blank.

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Say Cheese!We like to be able to put a name with a face :).

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Your date of birth* This field is required.

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Your gender* This field is required.

Female

Male

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Relationship

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Your cell phone number* This field is required.Notice: We offer communication via text message with medical providers for your convenience. (Plus we like the emojis. 😊👍🏼) Messages sent via standard SMS and iMessage are not encrypted or secured against third-party access. By providing your cell phone number here, you state that you accept these risks. (If you prefer a secure messaging system, please contact our team for an alternative.)

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Your email address* This field is required.

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Your home address* This field is required.

Street Address

Street Address 2

City

State

ZIP Code

Country

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What healthcare questions can we help you with?

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Have you had any past surgeries or medical procedures? If so, please list the type and date below.

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Do you have signs, symptoms, or a diagnosis of any of these conditions?* This field is required.Select all that apply. If you choose "Other," please type your condition within the "Other" box.

Cancer

Heart Condition

Diabetes

Asthma

Previous Surgery

Drug Allergies

Currently pregnant

I have no current symptoms or history of medical problems/issues or concerns.

Other

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Are you currently taking any medications? If so, please list the name, dosage, and purpose of the medication.

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Please list any allergies.

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How many family members are joining you?* This field is required.Family members must live in the same household and be a state recognized, legal marriage or guardianship. Dependent children must be age 25 or younger.

Just me

Me + 1 family member

Me + 2 or more family members

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Which family members are joining you?

Spouse

Child(ren)

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Are you and your spouse legally married as recognized by the state of Utah?* This field is required.Only legally recognized spouses may enroll under the same Alive & Well membership. The state of Utah does not currently recognize common-law marriage, though you may pursue a "judicially recognized marriage" (utah.staterecords.org/commonlawmarriage). If you have any questions, please reach out to us at info@myaliveandwell.com.

Yes

No

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Spouse Information* This field is required.Spouses must be a dependent by marriage. Please scroll to complete all fields.

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Are you a legal guardian of all children you are listing?* This field is required.You must have legal guardianship to enroll a child under your membership.

Yes

No

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Children's Information* This field is required.To be included on your membership, children must be a dependent by birth, legal adoption, or foster care. Children must be age 25 or younger. Please scroll to complete all fields. Click [+] to add another child's information.

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Please provide medical information for each family member included in your membership.* This field is required.Please click [+] to add another family member's information.

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Are there any other family member medical conditions or concerns you would like us to know about?

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Do you or does anyone in your household use tobacco or vape products?* This field is required.

YESNO

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Would you like to have your blood drawn as part of your initial enrollment benefits?* This field is required.

YESNO

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Notice of Complete Information* This field is required.

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Notice of Privacy Practices* This field is required.

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HIPAA RELEASE OF INFORMATION - This allows us to share medical information with people you choose, if needed: "By entering the full names of individuals, I authorize us to release medical information (including the diagnosis, records, and examination rendered to me as well as claims information) of family members on this membership to the individuals listed below. I also understand this does not take effect unless the full names of individuals are entered."NOTE: BY LAW, PARENTS OF MINORS AGES 12-17 WILL NEED PERMISSION FROM THEIR CHILD TO VIEW SOME OF THEIR MEDICAL INFORMATION.

Person 1

Person 2

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Consent* This field is required.By signing below, I acknowledge that I seek and consent to Alive & Well medical and wellness services. I agree to comply with all of the policies and procedures of the Alive & Well program, including those outlined in this enrollment form. I'm aware this consent does not cover treatment by providers or affiliates outside of the Alive & Well provider team. I certify that all information provided as part of this agreement is true and correct to the best of my knowledge. Finally, by signing, I'm aware that I, the enrollee, am stating that I was present for the filling out of this form.

Clear

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What language to you prefer for future communications with us?¿Cuál es su idioma preferido para futuras comunicaciones con nosotros?

English

Español

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Bank Name* This field is required.

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Bank Location (City, State)* This field is required.

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Type of Account* This field is required.

Checking

Savings

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Full name of the person listed on the account* This field is required.

First Name

Last Name

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Account Number* This field is required.

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Routing Number* This field is required.

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Signature* This field is required.I authorize Alive & Well™ to debit my bank account on the first of each month for payment of my direct primary care membership fees. I understand and agree that any and all requests for changes in my account information, including requests to terminate this agreement, must be received by Alive & Well™ by the 25th of the month prior to the next due date. If the payment due date falls on a weekend or holiday, the payment may be executed on the next business day. I understand and agree that as this is an electronic transaction, enough funds must be available for withdrawal from my account by the payment due date. In the case of an ACH transaction being rejected for Non-Sufficient Funds, or any other purchaser error, Alive & Well™ may at its discretion resubmit the ACH debit transaction, including a 3.5% late charge. I acknowledge that the origination of ACH transactions to my account must comply with provisions of U.S. law and agree not to dispute this recurring billing so long as the transactions correspond to the terms indicated in this authorization form.

Clear

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Please let us know who referred you:

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What would make healthcare better for you?

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Last, but not least, what's something on your bucket list?