Please Click on each of the FIVE forms below to open a PDF file format form for you to print and complete. (We will gladly send you paper forms if you wish by contacting us at [email protected] OR calling us at (608) 482-2005.)
We do need a signature on each of the forms. If forms do not open automatically - then RIGHT click and select "Open in a new tab."
One per family on forms 1, 2, and 3:
1. Membership Application - Basic information and questions to help decide eligibility for membership
2. Membership Agreement - Explains terms and what is expected of DIME Medical and what is expected of members
3. Billing Application Agreement - enables you to choose how you wish to pay for membership
One form PER PERSON on forms 4 & 5:
4. Past Medical History Form - gives us your background health history
5. Medical Release form - allows us to request your medical records from your former doctor.
EMPLOYERS - may use the following Billing form in place of #3 above. If employers are not paying for all of the potential billing services, then each employee should also complete a billing application #3 above to allow for billing of service NOT covered by employer. For example, if the employer is paying monthly membership fee but NOT for labs, then both forms should be completed.
Employer's Billing Application Agreement - Employers may choose how and what to pay for their member employees.
THEN return to us in one of the following ways:
1. Scan signed forms and attach to an email and send back to us at [email protected]
2. Or Fax signed forms to us at (855) 574-5406
3. Or Mail back signed forms to us at
DIME Medical, 340 Main Street, Darlington, WI 53530
4. Or drop off the signed forms in person at our office.