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Add Member
* Personal Information
Full Name
Father Name
Mother Name
Email address
Mobile No
Alternate Mobile Number
Gender
Select User Gender
Male
Female
Transgender
Birth Date
Do you have Ayushman card?
Yes
No
Ayushman Card No
Member Ayusman Card
Choose file
Are you married?
Yes
No
* Permanent Address
Address
State
Uttar Pradesh
District
Select District
Block / Tehsil
Select Tehsil
Village
Select Village
Pin Code
* Mailing Address
Copy Permanent Address to Mailing Address
Address
State
Uttar Pradesh
District
Select District
Block / Tehsil
Select Tehsil
Village
Select Village
Pin Code
* Identification Documents
Document Type
Select Type
Adhar Card
Pan Card
Recidential Document
Document upload
Choose file
Member Profile Image
Choose file
* Financial Information
Annual Income Certificate
Choose file
* Medical Information
Medical Condition
Previous Healthcare Coverage
Preferred Primary Care Provider
* Upload Signature
Upload Signature
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* Declaration
I declare that the information provided is true and accurate to the best of my knowledge.
