Always There.

Friends And Family



Welcome to our family!

At DMC, we’re taking the hassle out of healthcare, and we’re starting with you.

To enroll in the DMC Friends & Family program, and start receiving the benefits of streamlined, faster service, complete the registration form below. We’ll send you your welcome kit, including your membership card, in the mail in a few weeks.

We look forward to exceeding your expectations – thanks for choosing the DMC.


Online Registration:
All fields marked with * are required
Preferred DMC Facility:*
select
Where did you hear about DMC Friends & Family?*
Registration Details:
Are you a DMC Employee:*
Enter your Legal First Name:*
Middle Initial:  
Enter your Legal Last Name:*
Suffix:
select
Are you a Non-DMC
AFSCME Employee:*
Address:*
Apt Number:
City:*
State:*
Zip Code:*
Home Phone:*
Work Phone:
Work Phone Extension:
Mobile Phone:
Please choose the best
contact number:
Email Address:
Preferred Method of
Communication:
Birthdate:*
Gender:*
select
Marital Status:*
select
Family Doctor:
Phone:
Insurance Information:
Primary Health Insurance: *
Secondary Insurance:
Name on the Insurance Card:
Subscriber's Birthdate:
Insurance ID Number:
Contract/Group Number:
Emergency Contact:
Name:
Phone:
Address:
Apt Number:
City:
State:
Zip:
Referring Employee:
Name:
Phone:
Address:
Apt Number:
City:
State:
Zip:
Survey 2:
Yes, I would like to receive regular health information by
Security Code:  
 
 
*Type Security Code:  

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