Annual Access Membership

at HOME Annual Access

Start Your At HOME Annual Access Subscription

Complete this form to enroll in the Annual Access plan and securely enter our system. This step gives you access to your electronic health records, priority scheduling, and ongoing communication with our team.

You will also have the option to choose an At HOME concierge care plan, Basic Prepaid Care, or Comprehensive Primary Care. This selection helps our staff prepare for the next steps. After submission, our team will contact you to finalize your chosen care plan and answer any questions.

Annual Access Membership

The information provided will be used to create your online portal access. *Must be 16 years or older to join.

Name(Required)

First Last

Phone(Required)

Email(Required)

Date of birth(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region

Zip Code *Some zip have an additional cost.(Required)

We currently only serve these zip codes. If you live outside these zip codes, please check back as we will be expanding in the future.

Choose your care plan below.(Required)

Annual Access - *required for all services = $50

Annual Access ($50) & Basic Prepaid Care Plan add-on ($500) = $550

Annual Access ($50) & Comprehensive Primary Care Plan add-on ($2400 will be billed separately by email and patient portal)

Total

Credit Card(Required)

Cardholder Name

Card Details