New Patient Enrollment

New Patient Enrollment (Required for Assisted or Independent Living patients only)

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There are two options available to complete the New Patient Enrollment forms. The first option allows you to complete the forms online via DocuSign. The second option allows you to download and print the forms, complete them, and return them to us by mail or fax. Please do not complete the forms using both options.

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Instructions to Complete Online

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The link below will direct you to the New Patient Enrollment forms via DocuSign where you will complete all forms online. Before proceeding, please gather the following documents:

• Any advanced Directives documents, MOST forms, Living Wills

• Power of Attorney, Guardianship, or Conservatorship documents

• Insurance Cards

• Medication Lists

• List of Diagnosis

• Contact information for previous primary care physician

• Phone numbers for emergency contacts

• Driver's license or State ID

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When completing the enrollment forms, please note that you can upload any documents using any one of the paper clip icons on the left side of the pages to save time.

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                                          Example of the paper clip icon used in the document

                                                        for uploading pictures or documents.

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When you proceed to the forms by using the "New Patient Enrollment" button below, you will be prompted to enter an email address to verify your identity. This is to protect any  HIPAA information you disclose during enrollment.

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If you have any questions, please contact Angella Kingston at 720-698-1647.

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Instructions to Download, Print, and Mail or Fax

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If you are unable to complete the New Patient Enrollment forms online, or if you prefer to print the forms, the link below will redirect you to the New Patient Enrollment packet, which you can download, print, complete, and return to us by mail or fax. Please note that when completing the forms, you will need to gather the same information listed above. Please include a copy of your insurance card, driver's license or State ID, and any other supporting documents with the completed forms.

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Mail completed forms and any supporting documents to:

Summit Medical Carolinas

9935-D Rea Road, Suite 324

Charlotte, NC 28277

Fax: 980-580-4749

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If you have any questions, please contact Angella Kingston at 720-698-1647.