Clients Interested in our Services

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Last Name *

First Name *

Are you a Columbia County Resident? (We serve only residents of Columbia County at this time) *

Yes

Street Address *

City/Town *

State *

New York

Zip Code *

Phone number (with area code) *

Date of Birth *

YYYY

Email address

Social Security number

Insurance (Please choose one of the following accepted insurances. If you do not use one of these insurance companies, please call the number on the back of your insurance card for in network providers. You can also call the Healthcare Consortium at 518-822-8820. If you still need services through us, please call our office at 518-828-9446) *

Medicaid

Medicaid Managed Care CDPHP

All Fidelis insurance

Medicaid Managed Care United Healthcare

Medicare

Child Health Plus

Any insurance associated with Medicare

Tricare Veteran's Insurance

The Essential Plan

CDPHP (for Columbia County employees only)

Medicaid Managed Care

Self pay

Other:

Insurance ID Number *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Columbia County, NY. Report Abuse

Forms