Clarity

Welcome to the Care Continuity Program!

To enroll in the Care Continuity Program, fill in the information requested below.

If you need any assistance filling out this form, please contact us at 866-517-2771.
(Note: CCP Call Center Representatives are not authorized to give out Clinic Pin numbers over the phone.)

First, enter the Clinic Pin you were given, then click 'Search for Physician'. Your Clinic Pin is on your Care Continuity Program handout.

Clinic Pin:

(If you don't know your Clinic Pin, that's okay. Contact your healthcare provider and they can provide you with your pin number.)

Referring Physician:

First Name:

Birthday:

Last Name:

Last 4 of SSN:

Gender:

Mailing Address:

City:

State:

Zip:

By checking this box, I agree that the information entered above is true and correct to the best of my knowledge and authorize all information to be sent to the healthcare provider listed above.