Sign Up for
New Members

Join today with two easy steps to have Patient Sortal manage your healthcare needs

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PS

Delaware
New Member Enrollment Form

Step 1:

Step 1: Please fill out the following health declaration form in order to participate in our activity. Submissions are valid up to 24 hours prior to the activity.

First Name

Last Name

DOC #

Projected Release Date

Incarceration Date

Facility Located

Please note North / South/ East/ West of facility.

Phone

Reentry Point of Contact

Reentry Point Of Contact Email

I confirm I have Read thePrivacy Policy

I confirm that I have Read and Agree to Terms of Service

Step 2:

Thanks for submitting! Please move to step 2!

Step 2: Click Button below then, Fill out and Sign Patient Sortal HIPAA Right of Access. This document allows us to manage our Members Health Records. This form must completed, signed, and emailed to contact@patientsortal.com upon completion

Patient Sortal's HIPAA Right of Access

Member Card

Step 3:

Member Card

Member Sign up

Employee Login

PS

Sign Up for
New Members

PS

Delaware
New Member Enrollment Form

Step 1:

Step 1: Please fill out the following health declaration form in order to participate in our activity. Submissions are valid up to 24 hours prior to the activity.

Step 2:

Member Card

Step 3:

contact@patientsortal.com

Member Services
1-833-PAT1ENT or 1-833-728-1368

Fax
+1 (844) 927-5012

consents

Privacy Policy

Terms of Service

PS

Sign Up for New Members

PS

Delaware New Member Enrollment Form

Step 1:

Step 1: Please fill out the following health declaration form in order to participate in our activity. Submissions are valid up to 24 hours prior to the activity.

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Step 2:

Member Card

Step 3:

Sign Up for
New Members

Delaware
New Member Enrollment Form