Tell us about yourself.

• First Name^*
• Last Name^*

• What is your date of birth?^*

  Month of Birth MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day of birth Day12345678910111213141516171819202122232425262728293031 Year of birth Year1930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020

How can we contact you?

• What is a cell phone number where we can reach you?^*
• If possible, provide an alternative phone number.
• For Video Visits, do you have the WhatsApp message app on your phone? YesI need help
• Do you have an email address?^* YesNo
  What is your e-mail address?^*

Who is your Health Insurance Provider?

• If possible, choose an insurance provider. Please Select Insurance Provider1199 National Benefit FundAarp Healthcare OptionsAccess Medicare AdvantageAdministrative Concepts IncAetna Insurance CompAffinity (Medicare, Medicaid)America’s Choice Health PlanAmerican Health MedicareAmerichoice Of Uhc (Medicare, Medicaid)Amerigroup Community CareAmerihealthAmidacareApostles Of Jesus MissionariesApwu Health PlanArchcare AdvantageBlue Cross Blue Shield (Blue Card, Blue Choice, Empire, Federal Employee)Bricklayers Ins & WelfareCapital District Physicians Hp, IncCare Improvement PlusCareplus Health Plans, IncCenter Light Health CareChesterfield ResourcesCigna (Apwu, Behavioral And Health, HealthPlan, International, Medicare Advantage, Mvp)Fidelis (Medicare, Medicaid)Ghi (Guildnet, Hmo, Network Access, Ppo)Government Employee HealthGreat West HealthcareHealthcare Partners (Hip, Liberty, Touchstone)Healthfirst (Medicare, Medicaid)Healthnet (Uhc)Healthplus (Medicare, Medicaid)Hip Palladian HealthHip Plan Of New YorkHip/Vip/MedicareHomefirst ElderplanHorizon Bcbs NjHudson Health Plan CaidHumana IncInternational Benefits AdminKey Benefit AdministratorsLiberty Health AdvantageMagnacareMail Handlers Benefit PlanMaloney AssociatesMedicaidMedicareMedsolutionsMeritain InsuranceMetroplus (Medicare, Medicaid)Mmm InsuranceMontefiore IpaMultiplan(Locals)Natl Asso. Letter CarriersNatl Heritage Insurance CompanyNeighborhoodNew York Organ Donor NetworkNew York Presby-Select HealthNippon Life BenefitNo FaultOmni AdministratorsOptum HealthOrthonet CorporationOxford Health PlansOxford LibertyPan-American Life Insurance CompPhcsPhcs (Hcc Medical)Plan Administrators IncorporatedPomco InsurancePreferred Mcr ChoiceRailroad MedicareRelay HealthSenior Health PartnersSenior Whole HealthSeven CornersSpiro SayeghStarmarkToday’s OptionTotal Care IncTouchstone HealthTricare StandardTristate Benefit SolutionsUmr/Benesight InsUnicareUnited Healthcare (Empire Plan, Student Resources)Universal Health CareUs Family Health PlanValue OptionVillage Care MaxVns Choice Select (Medicare, Medicaid)Wellcare (Medicare, Medicaid)Workers CompOthers
• I’m not sure and could use help.

What can we help you with today?

Choose any one to get started, don’t worry, we’ll help you sort it out. *

• I don’t feel well
• I think I have COVID-19
• I need a prescription refill
• I need a test
• I need to talk to my doctor
• I want to make or change an appointment
• I have a question or want to talk to someone
• I have a billing or insurance problem
• I want to complain or give a compliment
• I am a new patient
• Other