Enrollment Form

Enrollment - University of Miami

University of Miami - PrEP & RW

1951 NW 7th Avenue, Suite #480

Miami, FL 33136

305-243-2584

305-243-4598

Select Group Code

Appointment Date

Next Appointment Date

MRN

Re-enter MRN

Patient Name

First Name

Last Name

Preferred Name

Patient Date of Birth

Patient Phone

Patient Email

Delivery Address

Street

Delivery Address

City

State/Province

Zip/Postal

Language Preference Language Preference

What Services is the Patient Receiving?

PrEP

HIV Treatment

Rapid Start

Is Patient 340B Eligible?

Yes

No

Is Patient Eligible For Financial Assistance? (If Yes is checked, patient will receive 100% financial assistance.)

Yes

No

Does Patient Have Allergies?

YesYes

No

Unknown

Insurance

Pharmacy Insurance Name

Rx BIN #

Rx PCN #

Rx ID #

Group or Plan #

Enrolled By:

Medication Packaging (Choose One)

Bottles

Medication Adherence Packaging

Additional Details (Use this field to provide additional information or preferences)

Start Over

If you are human, leave this field blank.

phone

866-460-8040

Headquarters

200 Technology Ct., Suite B
Smyrna, GA 30082

E-mail

customerservice

@curanthealth.com

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