Primary Care Plan Enrollment
Registering as a patient of:
Dr. Schwartz
Number of members registering
1
2
3
4
5
6
Primary Family Member and DOB
Primary Member Plan Choice
299-0
149-25
99-40
Additional Names and DOBs
2nd family member plan choice
299-0
149-25
99-40
3rd family member plan choice
299-0
149-25
99-40
4th family member plan choice
299-0
149-25
99-40