Case/Disease Management Enrollment

Disease & Case Management

NMHC has two programs to help you. Disease Management provides support for any member who has been diagnosed with Diabetes or Asthma. Case Management provides support with any member who has been diagnosed with a complex health issue. If you would like to enroll in either program, simply provide the information on this form and we will contact you. These programs are available at no additional cost to you.

First Name:

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* 1. First Name:

Last Name

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* 2. Last Name

Date of Birth

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* 3. Date of Birth

Date

Member ID (as listed on your card)

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* 4. Member ID (as listed on your card)

I want to enroll in:

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* 5. I want to enroll in:

Asthma Disease Management

Diabetes Disease Management

Case Management (select this program if you have a complex medical issue)

If you selected Case Management, please describe requested services

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* 6. If you selected Case Management, please describe requested services

Phone Number (best number to contact you)

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* 7. Phone Number (best number to contact you)

E-Mail Address

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* 8. E-Mail Address