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Enrollment in Health Network

Enrollment in Health Network

Health Network Enrollment Packet


Health Network Enrollment Packet [English]

Health Network Enrollment Packet [Creole]

Health Network Enrollment Packet [Portuguese]

Health Network Enrollment Packet [Spanish]


Enrollment is free and must be initiated by the clinic. A patient cannot enroll him/herself.

The 3 things required for enrollment are:

  1. CONSENT FOR RELEASE OF MEDICAL INFORMATION section (signed and dated)
  2. PARTICIPANT INFORMATION SHEET section (including the patient’s working phone number(s) and intended address)
  3. Medical records and/or summary of next steps
How to Enroll


Download the Enrollment Packet (2 pages) on this website page. You fill out the pages and have the patient sign. You fax it back to us along with the patient's medical records.


Call 512-327-2017 (with the patient present), we interview the patient, explain the program to the patient, we fill in the Enrollment Packet for you and send them to you. Have the patient simply sign, and then fax those back to us along with all of the patient's medical records.

Please fax completed Enrollment Packets to: 512.327.6140

Once we receive this paperwork, we will verify the information and initiate case management. It is critical that you fill this enrollment packet out as completely as possible so that MCN staff can provide the best possible service to you and your patients. We recommend enrolling patients in anticipation of their departure; having a patient enrolled ahead of time will enable us to direct that patient to their next clinic before the patient leaves your area. Only patients enrolled will be followed. Health Network has been designed to facilitate the continuity of care for these mobile patients, not only in the U.S., but around the world.


Informational Videos about Health Network



If you have any questions about enrolling patients in Health Network, please feel free to contact
Theressa Lyons-Clampitt, Training and Technical Assistance Coordinator