Facility Information Enrollment Information - 360care 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Facility Information' section. Enter the facility name, address, city, state, and zip code accurately.
3. In the 'Patient Information' section, provide the patient's first name, middle initial, last name, gender, date of birth, and Medicaid number if applicable.
4. Complete the 'Legal Representative Information' if applicable. Include their name, relationship to the patient, and contact details.
5. Move on to 'Payment Information'. Select how bills will be sent and fill in payment details for credit/debit cards or bank accounts as required.
6. Review all entered information for accuracy before submitting. Ensure that you have signed where indicated.

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