Electronic Enrollment

eSign Enrollment Form

Complete the form below to begin your enrollment with Purple Health. All submissions are processed securely and in compliance with applicable regulations. For assistance, call us at 833-879-1578.

First Name *

Last Name *

Company Name

Email Address *

Phone Number

Member ID

Electronic Signature Agreement *By checking this box, I agree to use electronic signatures and records in connection with this enrollment form. I understand that my electronic signature has the same legal effect as a handwritten signature. I confirm that I have received, reviewed, and understood the plan documents associated with my enrollment, including the Summary of Benefits, Schedule of Benefits, and any applicable Certificate of Coverage, and I am signing in acknowledgment of those documents. I consent to conduct this transaction electronically and acknowledge that I have read and agree to the Terms & Conditions and Privacy Policy of Synergy Health Associates LLC DBA Purple Health. I may withdraw this consent at any time by contacting us at support@getpurplehealth.com or (833) 879-1578.

By checking this box, I consent to receive transactional text messages related to my account or services I requested from Synergy Health Associates LLC DBA Purple Health, sent from (877) 217-0431. These messages may include appointment reminders, service confirmations, and account notifications among others. Message frequency varies, message & data rates may apply. Reply HELP for help or reply STOP to opt out. For assistance, you can contact us at (877) 217-0431.

By checking this box, I consent to receive non-marketing messages including billing updates, electronic signatures links, refund notifications and others from Synergy Health Associates LLC DBA Purple Health, sent from (877) 217-0431, at the phone number provided. Message frequency varies, message & data rates may apply. Reply HELP for help or reply STOP to opt out. For assistance, you can contact us at (877) 217-0431.

Authorized Signature

Printed Full Name *

Date

October 17, 2026

Draw Signature *

Sign above

By drawing your signature above, you acknowledge that this electronic signature is legally binding and equivalent to your handwritten signature under the Electronic Signatures in Global and National Commerce Act (E-SIGN Act, 15 U.S.C. § 7001 et seq.).

Your information is protected under our privacy policy and handled in accordance with HIPAA, TCPA, and ESIGN Act regulations.