The best way to enroll in DocuBank is through an estate planning professional. To find a DocuBank Provider in your area, please call 866-829-0993.
To enroll on your own: Complete the enrollment form below. Next, print it out and sign it. (Alternatively, you can print the form and then fill it out by hand.)
Send the following materials to DocuBank:
Mail the enrollment materials to: DocuBank P. O. Box 629 Springfield, PA 19064
The names and phone numbers of your emergency contacts and physician will be provided to hospital staff when your documents are requested. If your living will, health care power of attorney, or other advance directive names people to make decisions for you, please list up to three of them here in the same order. If no one is listed in your documents, you may choose up to three people as emergency contacts and list them here.
Contact 1
Contact 2
Contact 3
Primary Care Physician
Permanent medical condtions to appear on the front of the card:
Please note: Each member must complete a separate enrollment form.
Name of professional organization or individual referring you (if applicable).*
*If you are enrolling without the help of a DocuBank attorney or advisor, and would like to find one in your area, visit our Attorney/Advisor Finder. We'll contact you with the names of professionals who are using the service for their clients.
I have completed an advance directive document(s) (e.g. living will, health care power of attorney, HIPAA authorization, and/or organ donation information) of my own free will and have chosen to enroll in DocuBank to help make my document(s) available when requested. To ensure prompt access, I authorize that my document(s), emergency contact and health information stored with DocuBank be accessible to anyone who provides the member number and PIN on my card. I will notify DocuBank promptly of changes in any of my stored information, and also of the revocation or replacement of my document(s). I understand that DocuBank is not responsible for the validity or accuracy of any information stored by DocuBank, including the health information that also appears on my card. I understand that: by accepting my card I have verified and confirmed the accuracy of all information on the card before carrying it; by providing a fax number for my physician, I am granting DocuBank permission to fax an enrollment notification enabling this physician to obtain my directives; that DocuBank does not provide legal advice; and that I may cancel this service in writing by written request to DocuBank.
Remember to sign this form and enclose a clear copy of your document(s) with this form and your payment.
