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Family & Friends

SCAN Family & Friends Program – Register Today!

All the information fields below must be completed.

SCAN Member Name

Member # or Date of Birth

Family/Friend Information

Name of Family Member/Friend

Mailing Address

City		State		Zip

Phone

Email

Relationship to SCAN Member

Relative (indicate relationship)
Friend
Caregiver to SCAN Member

This individual will begin receiving general SCAN member and benefits information in the mail.

Please send my family or friend literature in Spanish

SCAN will not sell or share any provided names or personal information to other companies, and no personal medical information will be provided or shared through this program.