Enrollment | Fidelis Care

Member Name*
First Last
Mobile Number*
If you are enrolling a child and parent/guardian under Medically Fragile Children, please indicate the parent/guardian's mobile number below.
Group ID*
Plan ID*
Member ID*
Suffix*
Date of Birth*
MM slash DD slash YYYY
Ethnicity*
- Hispanic or Latino
- Not Hispanic or Latino
- No response
Race*
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or Other Pacific Islander
- White
- No response
County*
Region*
Please Select Preferred Language*
- English
- Spanish
Select Applicable Conditions
Member may enroll in 2 primary conditions (2-3 message/week/condition) and 2 secondary conditions (1 message/month/condition). You must select at least 1 primary condition.
Select 1-2 primary conditions*
- General Health and Wellness
- Asthma
- Behavioral Health
- Congestive Heart Failure
- COPD
- Diabetes
- At Risk Pregnancy
- Medically Fragile Child(ren)
- Transitions of Care
- Emergency Room Reduction
Select 1-2 secondary conditions (optional)
Must be different from primary conditions.
- Asthma
- Behavioral Health
- Congestive Heart Failure
- COPD
- Diabetes
- At Risk Pregnancy
- Medically Fragile Child(ren)
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What is your current weight?*
Please enter your current weight in in pounds.
Due Date*
Please indicate the expected due date for the at-risk pregnancy
MM slash DD slash YYYY
Is the member pregnant with a substance dependence?*
- Yes
- No
Please check any substance dependencies that apply*
- Opioid
- Other
What "other" substance is the member dependent on?*
Parent / Guardian Name*
First Last
Quality of Life
Please check the items that are impacting the member’s quality of life.*
(Please select all that apply.)
- Economic Stability
- Education
- Social and Community Context
- Health and Healthcare
- Neighborhood and Built Environment
- Member reports no current concerns impacting quality of life
Please specify economic challenges:*
- Employment
- Food Insecurity
- Housing Instability
- Poverty
- Other
What other economic challenge is impacting the member's quality of life?*
Please specify education challenges:*
- Early Childhood Education and Development
- Enrollment in Higher Education
- High School Graduation
- Language and Literacy
- Other
What other education challenge is impacting the member's quality of life?*
Please specify social and community context challenges:*
- Civic Participation
- Discrimination
- Incarceration
- Social Cohesion
- Other
What other social and community challenge is impacting the member's quality of life?*
Please specify health and healthcare challenges:*
- Access to Healthcare
- Access to Primary Care
- Health Literacy
- Other
What other health or healthcare challenge is impacting the member's quality of life?*
Please specify neighborhood and built environment challenges:*
- Access to Foods that Support Healthy Eating Patterns
- Crime and Violence
- Environmental Conditions
- Quality of Housing
- Other
What other neighborhood or built environment challenge is impacting the member's quality of life?*
Add a Caregiver, Partner, or Loved One
Does the member want to sign up a loved one, partner or caregiver who shares in their care to receive the same messaging?*
- Yes
- No
Caregiver Name*
First Last
Caregiver Mobile Number*
Caregiver Authorization*
- I authorize a one-time communication to my caregiver to confirm their enrollment in the program. By checking this box, I also provide electronic consent for my caregiver to receive my Personal Health Information via text messages to the mobile number provided.
Brief Survey
Below are some statements that people sometimes make when they talk about their health. Please indicate how much you agree or disagree with each statement as it applies to you.
When all is said and done, I am the person who is responsible for managing my health condition*
- Strongly Agree
- Agree
- Not Sure
- Disagree
- Strongly Disagree
Taking an active role in my own health care is the most important factor in determining my health and ability to function*
- Strongly Agree
- Agree
- Not Sure
- Disagree
- Strongly Disagree
I am confident that I can take actions that will help prevent or minimize some symptoms or problems associated with my health condition*
- Strongly Agree
- Agree
- Not Sure
- Disagree
- Strongly Disagree
I am confident that I can tell when I need to go get medical care and when I can handle a health problem myself*
- Strongly Agree
- Agree
- Not Sure
- Disagree
- Strongly Disagree
Privacy Policy*
We’re just about done signing you up. Once I complete your enrollment, you will receive a confirmation text message containing a link that will take you to the program’s terms and conditions, as well as some HIPAA information for you to read through. With that being said, I do need you to confirm that you understand that text, like email, is not considered a secure technology and that the messages you receive may indicate the nature of your condition. However, beyond the general nature of your condition, this program does not send Protected Health Information (PHI) via text. Do you accept?
- I agree to the privacy policy.
Electronic Consent*
The Telephone Consumer Protection Act generally requires us to obtain consent before contacting members on their mobile phones. By enrolling in this program, you are granting consent to Fidelis Care and/or GoMo Health to contact you via text message to the number you are enrolling with. Text messages may include health care information related to your healthcare services. Please note that depending on your mobile phone service plan, message and data rates may apply to your mobile provider. You also confirm that you are the wireless subscriber or owner of the mobile number provided and have authority to provide consent. You may opt-out at any time by replying STOP or STOPALL.
- I have verbally completed the enrollment form and provide electronic consent to enroll. I grant permission to Fidelis Care and/or its GoMo Health to contact my cell phone via text messages.
Enrolled by*
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Enrolled by Value
Enrolled by*
First Last
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IsChronic
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DaysCalc
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OptinDate
MM slash DD slash YYYY
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PrimaryPregSubstance
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PrimaryPregSubstanceES
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SecondaryPregSubstance
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SecondaryPregSubstanceES
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PrimaryPregNoAbuse
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PrimaryPregNoAbuseES
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SecondaryPregNoAbuse
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SecondaryPregNoAbuseES
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StartPoint
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PrimaryPregChat
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PrimaryTransEmerg
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FragileOnly

Member Enrollment

Select Applicable Conditions

Quality of Life

Add a Caregiver, Partner, or Loved One

Brief Survey