Essential Telehealth Services

Essential Telehealth – New Patient Registration

First Name *

Date of Birth *

Last Name *

Sex/Gender *

Other:

Social Security Number (last 4 digits)

Phone Number *

Email Address *

Street Address *

ZIP Code *

City *

State *

Medicaid ID Number (Member ID)

State Medicaid Plan

Group Medicaid Plan

Group/Plan Number

Primary Insurance Type

Medicaid Both, Medicare Private Uninsured

Insurance Carrier Name

Guardian Full Name

Relationship to Patient

Guardian Date of Birth

Guardian Phone

User Password *

Confirm Password *

* Required for Medicaid electronic billing