DHP: Home Visit Registration Form 1.0

Step 2: Enter information as seen on your Driscoll Health Plan Card

To make sure you are registered for one of our classes, please review the information below as seen on your Member Identification Card.
Name*

First NameLast Name
Line of Business*
Date of Birth*

MonthDayYear
Members who participate in a DHP Home Visit within 60 days after delivery earn a $20 gift card for attending one DHP educational Home Visit class. *Restrictions and limitations may apply.
Mailing Address*
Street Address
City*
City
State*
State
Zip Code*
Zip Code
Phone Number*
Please enter a valid phone number.
Email

Confirmation Emailexample@example.com
May we text or email you class information?*

TextEmail
Be sure to check your emails for class schedule reminder.

Step 3: Enter information to continue with registration
Date of Delivery*

MonthDayYear
Date
Current*

MonthDayYear
Date
C Date*

MonthDayYear
Date
Days since delivery*
Thank you for your time. At this time, you are not eligible for this class. Please call Member Services to get more information about other educational classes.

Step 3: Enter information to continue with registration