Complete the enrollment form below. Once your membership has been processed you will receive a confirmation email. PLEASE REFERENCE YOUR CONFIRMATION NUMBER ON YOUR DOCUMENTS.
To submit your documents:
EMAIL the information as .pdf attachments to: firstname.lastname@example.org
FAX the information to: 610-667-1483
MAIL the information to: DocuBank®, P. O. Box 629, Springfield, PA 19064
Red fields are required.
Orange fields are strongly suggested.
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.
Primary Care Physician
Permanent medical condtions to appear on the front of the card:
Please note: Each member must complete a separate enrollment form.
We will contact you for your credit card information. Please call 866-829-0993 if you have any questions.
Name of professional organization or individual referring you (if applicable).*
*If you are enrolling without the help of an attorney or advisor, and would like to find one, visit our Attorney/Advisor Finder. We'll contact you with the names of LGBT-friendly professionals who register their clients in DocuBank.
A portion of your DocuBank registration fee will be donated to HRC.
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.