Case Manager Mini-Concierge Program Enrollment

Questions marked with an asterisk (*) are required.

Member Name*

First Last

Mobile Number*

Member ID*

Which Condition track is the Member being enrolled in*

Sleep
Chronic Pain

NOTE: THIS IS A CASE MANAGER SCRIPT. PLEASE COPY AND PASTE THE SCRIPT BELOW IN CHAT WHEN ENROLLING A MEMBER.

Consent*

We’re almost done enrolling you. By agreeing, you’ll receive additional text messages. Please confirm you understand that text messaging, like email, is not secure and messages may indicate the general nature of your condition. This program does not send Protected Health Information via text. Messages use your standard text plan, with no additional charges. Do you accept?

I have completed the enrollment form, provided electronic consent to enroll the patient in additional tracks, and the patient grants permission to Fidelis Care and GoMo Health to contact their cell phone via text message from the phone number 52046.

Enrolled by*

Hidden

Enrolled by Value

Enrolled by*

First Last