SECURE: Member Enrollment – CHCW Prescription Discount Program Please enable JavaScript in your browser to complete this form.Is this a new member enrollment or annual renewal? *YesNo - Update of Effective DateWhich clinic does the patient use? *Central Washington Family Medicine (CWFM) YakimaYakima PediatricsNaches Medical ClinicHighland ClinicDavis Health ClinicEllensburg Medical ClinicEllensburg Dental ClinicCovering Hospital Charges OnlyName *FirstLastDate of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920ID #: *Group *CHCWACHCWBCHCWCCHCWDHS1 (Pharmacy Only – Catastrophic Coverage)HS2 (Pharmacy Only – Chronic Prescription Hardship)Effective Date *Expiration Date *Maximum Expiration Date for SFS is 1 Year Maximum Expiration Date for Hardships is 6 months: January – June February – July March – August April – September May – October June – November July – December August – January September – February October – March November – April December – MayCommentSubmit
