Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Passport to Care Registration & Payment May

  1. Passport to Care Registration

  2. Sign in or create an account and your submitted forms will be saved and accessible to you.

  3. Thank you for deciding to become a member of our Passport to Care plan. Simply follow the steps below, provide us with all the information, and provide payment on the next screen, by phone, or in person.

    Our membership plan is designed with an unlimited open enrollment period. This means you can join at any time. All memberships will begin on January 1, 2020 or at one minute past midnight on the day following when your membership is received whichever is later. After our initial enrollment period is completed on February 28, 2020, the membership fee will be pro-rated throughout the remainder of the calendar year on a month to month basis.

    ALL Passport to Care Memberships expire at 11:59 P.M. on December 31.

  4. Service Area Agreement*


  5. Head of Household

    Please enter the following information for the head of the household.

  6. Head of Household Insurance Information

    Please enter the following information pertaining to the head of household's insurance.

  7. Secondary Insurance

    Please enter the following information pertaining to any secondary insurance, if applicable.

  8. Dependents

    Please list any dependents you want included on the Passport to Care plan. If you need to add additional dependents, please call 210-619-1450 after submitting the application.

  9. Plan Information

    Select the applicable plan below. Joining in November or December includes the Membership fee for the following Plan Year.

    If you prefer to make your payment in person or over the phone, please call 210-619-1450 with your intentions.

  10. Plan Selection

    Please select the applicable plan from the drop down.

  11. Leave This Blank: