123-456-7890
3355 Cherry Ridge Dr, STE. 104, San Antonio, TX 78230
Be among the first to join the FiCare Family! Complete our pre-enrollment form to receive early access to membership details and have your one-time $75 enrollment fee waived when you enroll by December 31, 2026. We look forward to caring for you and your family!
Important Information for Medicare Beneficiaries
At this time, our practice is unable to accept patients enrolled or seeking care through Medicare. We encourage individuals enrolled in Medicare to contact their Medicare plan or visit "Medicare.gov" (https://www.medicare.gov/) to explore available healthcare options.
I understand that this form only expresses my interest in becoming a patient at FiCare Clinic. It does not establish a provider-patient relationship or guarantee enrollment.*
