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Establish Care
To establish care with one of our providers please fill out this form. We will contact you within two business days after receiving your information.
Please note that we do not accept Medicaid plans at this time. We no longer take UHC/UBH/Optum.
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* Indicates required question
What is your full name?
*
Your answer
What is your mobile phone number?
*
If you don't have a mobile number please use your home phone and write "home" after your number.
Your answer
What is your email address?
*
Your answer
What is your Date of Birth?
*
MM
/
DD
/
YYYY
Your Health Insurance?
*
Cash Pay
Premera Blue Cross
Regence Blue Cross
Aetna
Asuris
Cigna
First Choice Health
Medicare
Triwest
Magellan
What is your health insurance member ID number?
Your answer
What is your health insurance Group number?
Your answer
What kind of care are you seeking?
*
Pick the closest match. If you seek multiple care specialties, you can discuss that with your Patient Navigator when we call you back.
Medication Management
Therapy
FMLA (medical leave)
Psychiatric Evaluation or Diagnosis
Court Ordered Evaluation or Diagnosis
Life Coach, Career Coach
Nutritionalist
None of These or Unsure
Other:
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