Membership Application

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.

One per family on forms 1, 2, and 3:

1.  Membership ApplicationBasic information and questions to help decide eligibility for membership

2.  Membership AgreementExplains terms and what is expected of DIME Medical and what is expected of members

3.  Billing Application Agreementenables you to choose how you wish to pay for membership

One form PER PERSON on forms 4 & 5:

4.  Past Medical History Formgives us your background health history

5.  Medical Release formallows 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.


Haga clic en cada uno de los formularios a continuación para abrir un formulario de formato de archivo PDF para que pueda imprimir y completar.  (Con gusto le enviaremos formularios en papel si lo desea contactando con nosotros en [email protected])

Necesitamos una firma en cada uno de los formularios.

Uno por familia en los formularios 1, 2 y 3:

1.  Solicitud de membresía

2.  Acuerdo de membresía español

3.  Formulario de solicitud de facturación

Un formulario POR PERSONA en los formularios 4 y 5:

4.  Formulario de historial médico pasado

5.  Formulario de divulgación de información médica

ENTONCES regrese a nosotros de una de las siguientes maneras:

1. Escanee los formularios firmados, adjúntelos a un correo electrónico y envíenoslos a [email protected]

2. O envíenos por fax los formularios firmados al (855) 574-5406

3. O envíenos por correo los formularios firmados a

DIME Medical, 340 Main Street, Darlington, WI 53530

4. O entregue los formularios firmados en persona en nuestra oficina.