Membership Enrollment
Welcome to Dr. Sinai's concierge medicine practice. Complete the form below to begin your enrollment - your information is submitted through a HIPAA-secure channel.
What to expect
This enrollment form takes about 10–15 minutes. Have your insurance card and emergency contact information handy. Your responses go directly to Dr. Sinai's practice through a HIPAA-secure channel.
- 1
Personal info
Contact details & emergency contact
- 2
Insurance
Carrier & member ID, or self-pay
- 3
Sign & submit
Membership agreement & consent
Before you begin
Please complete this form in one sitting. You'll need about 10–15 minutes of uninterrupted time. Please have the following handy:
- Your insurance card (if applicable)
- Emergency contact name & phone number
- A current email address (any provider)
- Your membership payment preference
Your privacy matters to us.To protect your personal health information, we intentionally don't store partial responses — so if you need to step away, please come back and start fresh. If you'd prefer a paper version, call us at (702) 749-8891.
Membership Enrollment Form
Step 2: Clinical IntakeNew patients only
New patients:Please complete your medical history, allergies, medications, and health screening. Takes about 15–20 minutes.
Existing Dr. Sinai patients (transferring from IMS) - your medical records are already on file. You can skip this step.
Your privacy is protected.
This enrollment form is hosted on Google Workspace under a HIPAA Business Associate Agreement. Your responses are transmitted over an encrypted connection and stored in a HIPAA-compliant environment. See our Notice of Privacy Practices for details on how we handle your information.
Questions? Call (702) 749-8891 or email staff@drrebeccasinai.com.