Membership Application

Membership Application 2023-24:

ONLINE ENROLLMENT:

PAPER FORMS ENROLLMENT:

Please Click on each of the FIVE forms below to open a PDF file format form for you to print and complete.

We will gladly send you paper forms if you wish by contacting us at contact@dimemedical.org

OR calling us at (608) 482-2005.

We do need a signature on each of the forms. If forms do not open automatically - then RIGHT click

and select "Open in a new tab."

One form per family for each of forms 1, 2, and 3:

1. Membership Application (English and Espanol) - Basic information and questions to help decide

eligibility for membership

2. Membership Agreement - Explains terms and what is expected of DIME Medical and what is

expected of members (Espanol Acuerdo de membresía)

3. Billing Application Agreement - enables you to choose how you wish to pay for membership

One form PER PERSON for forms 4 & 5:

4. Patient Medical History Form (English and Espanol) - gives us your background health history

5. Medical Release form - allows us to request your medical records from your former doctor.

EMPLOYERS or 3rd Party Payors

- may use the following Billing form in place of #3 above.

If employers are NOT paying for all of the potential billing services, then each employee should also

complete a billing application #3 above to allow for billing of services NOT covered by employer.

For example, if the employer is paying monthly membership fee but NOT for labs or only for say

50% of labs or some other % less than 100%, then both forms should be completed.

Employer's Billing Application Agreement - Employers may choose how and what to pay for

their member employees as well as what percentage of charges.

THEN return to us in one of the following ways:

1. Scan signed forms and attach to an email and send back to us at Contact@dimemedical.org

- least secure so recommend NOT sending billing form back this way, even if you send other forms.

2. Or Fax signed forms to us at (855) 574-5406 - more secure than email

3. Or Mail back signed forms to us at

DIME Medical, 340 Main Street, Darlington, WI 53530

4. Or drop off the signed forms in person at our office.