Enroll Patients
Unlock Support and Resources
To complete enrollment, your patients will need to provide program consent and authorization to share health information.
Enrollment form
To initiate enrollment, fill out the form with your patient and submit it by fax or by email. Once the completed form is submitted, your patient's Case Manager will call you to confirm enrollment and discuss next steps based on the services requested.
Enrollment form
Download nowEnrollment form instructions
Download now
Fax
Submit at 1-866-370-3082
Additional ways to obtain patient consent
If your patients did not provide their consent in person, they can provide it online or in writing by downloading the consent form. Patients must provide their consent and HIPAA authorization to access YourBlueprint® services and support.
