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

Language Preference Language Preference

What Services is the Patient Receiving?

PrEP

HIV Treatment

Rapid Start

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

Yes

No

Insurance

Pharmacy Insurance Name

Rx BIN #

Rx PCN #

Rx ID #

Group or Plan #

Clinic Contact Name

First Name

Last Name

Medication Packaging (Choose One)

Bottles

Medication Adherence Packaging

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

If you are human, leave this field blank.

phone

866-460-8040

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Smyrna, GA 30082

customerservice

@curanthealth.com