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Passport to Care Registration

  1. Passport to Care Registration

  2. Thank you for deciding to become a member of our Passport to Care plan. Simply follow the steps below, provide us with all the information, and you will be contacted for payment. Your membership will be active the next regular business day.

    Our membership plan is designed with an unlimited open enrollment period. This means you can join at any time. All memberships will begin on January 1, 2019 or at one minute past midnight on the day following when your membership is received whichever is later. After our initial enrollment period is completed on February 28, 2019, the membership fee will be pro-rated throughout the remainder of the calendar year on a month to month basis.

    ALL Passport to Care Memberships expire at 11:59 P.M. on December 31.

  3. Head of Household

    Please enter the following information for the head of the household.

  4. Service Area Agreement*

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  5. Head of Household Insurance Information

    Please enter the following information pertaining to the head of household's insurance.

  6. Secondary Insurance

    Please enter the following information pertaining to any secondary insurance, if applicable.

  7. Dependents

    Please list any dependents you want included on the Passport to Care plan. If you need to add additional dependents, please call 210-619-1450 after submitting the application.

  8. Plan Information

    Select the applicable plan below. You will be directed to the payment screen upon completion. If you prefer to make your payment in person or over the phone, please call 210-619-1450 with your intentions.

  9. Leave This Blank:

  10. This field is not part of the form submission.