UCHM - Members Registration

Personal Data

e.g National ID, Drivers License, etc

Create Password (Can be created later)

*Password

*Confirm Password

Employer's Data

Primary Health Care Provider

Health Providers are based on State of Residence

Spouse/Biological Children

I. Spouse

Health Providers are based on Spouse State

II. Child 1

Health Providers are based on Child 1 State

III. Child 2

Health Providers are based on Child 2 State

IV. Child 3

Health Providers are based on Child 3 State

V. Child 4

Health Providers are based on Child 4 State

I hereby certify that all information provided above is true and correct to the best of my knowledge. *

Registration form