Thank you for choosing to participate in the HFM Chamber Clinic. Please complete the below form for each individual (employee, spouse, and dependents) you are enrolling.
Each participant will receive an HFM Chamber Clinic card with their name on it. That card must be shown at each clinic visit.
The HFM Chamber Clinic is open to Manitowoc Chamber member employees and their families. There is a $110 annual fee for each person enrolled in the clinic.
Please contact firstname.lastname@example.org for any questions regarding this form.
All applicable fields are required.
**Please note. Medicare and Medicaid beneficiaries or any insurance coverage under the Veterans Administration are not eligible to enroll in the HFM Chamber Clinic.