Enhanced Primary Care Enrollment Form

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Welcome to the Enhanced Primary Care Program

To request participation in the program please complete and submit the secure form below. One of our Health Navigators will contact you to complete the process. Download more information about Enhanced Primary Care or contact our Health Navigators, available to take your calls (toll free) at (833) 604-HILL (4455), Mon. - Fri. 8 a.m. - 10p.m., Sat. - Sun. 8 a.m. - 6 p.m. (closed holidays).

Member Enrollment

Would you like to enroll in the program?

Yes, I consent to enrolling in the Hill Physicians Enhanced Primary Care Program

No, I would like more information before enrolling in the program

Family Enrollment

This program is also available to the dependents under your medical plan

Would you like information about enrolling a family member in the Enhanced Primary Care Program?

Member Information

First and Last Name*

Date of Birth

Gender Identity

Choose not to disclose

Transgender Male/Female

Male

Transgender Female/Male

Female

Other

Member Zip Code

Member Health Plan Information

Only participating health plan members may request enrollment in the Enhanced Primary Care Program

Health Plan*

Health Plan ID

Employer Group*

Our Health Navigators can help with your healthcare needs. Please let us know what we can help you with:

Help finding or switching a primary care physician (PCP)

Help finding a pediatrician

Help finding a specialist

Medication assistance

Cancer screening

Women's health

Men's health

Chronic disease management

Lab tests

Other

Preferred communication for follow-up

Phone* Please check this box if you do not want detailed voicemail messages left at this phone number

Note: Please fill the required fields which are marked with ( * )

Enhanced Primary Care Enrollment Form

​​​​​​​​​​Welcome to the Enhanced Primary Care Program

Welcome to the Enhanced Primary Care Program