"*" indicates required fields Is this for a new or existing recipient?* New Existing Are you or this recipient:* Virtual only In-person only Both Virtual and In Person Existing recipients will be redirected to the patient portal to make appointments. Click the button below to proceed to the patient portal. This field is hidden when viewing the formContact Info SectionName* First Last Email* Phone*Date of Birth* MM slash DD slash YYYY How did you hear about us? Web Search (Google, Bing, Yelp) Social Media (Facebook, Instagram, LinkedIn) Person (Friend, Family, Colleague, Acquaintance) I’m not sure Other What other source did you hear about us from?* Please select a date and time below.(Optional) Date PreferenceAppointment requests must be confirmed by staff before they are finalized. Please call the office for urgent requests. MM slash DD slash YYYY (Optional) Preferred Times Early morning Late morning Around noon Early afternoon Late afternoon Other (Optional) Other Preferred TimesSelect your primary insurance plan.*Medicaid – OtherMedicaid – Aetna Better HealthMedicaid – AmeriHealth Caritas LouisianaMedicaid – Healthy BlueMedicaid – Louisiana Healthcare ConnectionsMedicaid – United Healthcare CommunityOtherUnknownEnter your insurance company's name.* This field is hidden when viewing the formWavier SectionWaiverI acknowledge that I am not including any protected health information (PHI) in my inquiry. I understand that any such information should be presented in person or securely over the phone with my health care provider. PHI, as defined by HIPAA (Health Insurance Portability and Accountability Act) includes, but is not limited to, any information that relates to 1) the past, present, or future physical or mental health or condition of an individual, 2) the provision of health care to an individual or 3) the past, present, or future payment for the provision of health care to an individual that identifies the individual or with respect to which there is a reasonable basis to believe the information can be used to identify the individual. I consent to allow any and all electronic communications with this recipient. These communications include this form and all others on this website, emails, text messages and website comments. I understand that electronic communication is not secure and that any information that I provide here may be visible to third parties or unintended recipients. I waive my rights under HIPAA to the extent that they can be waived and, in the event that any PHI is provided within this message or related messages, do not hold the recipient liable to any breaches or disclosures of the information provided in this message. I acceptCommentsThis field is for validation purposes and should be left unchanged.
