Fill out this short form to see if you qualify!

Fill out this short form to see if you qualify!

It usually takes about 2 minutes. Don't worry, your information is safe with us—this form is HIPAA-compliant to make sure your private information stays that way. Once you submit the form, our Customer Support team will reach out to you via email with next steps!
Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.
What state do you live in?*
What health insurance do you have?*
Ex: Medicaid, Community Health Plan of Washington
What is your health insurance member ID?*
What is your birthday?*

MonthDayYear
Date
What treatment center or clinic do you go to (if any)?
Would you be interested in funding your own membership?

YesNo
How did you hear about WEconnect?*

From a friend or family memberFrom my doctorFrom my health insuranceFrom my treatment centerFrom my social mediaFrom Google or another search engineOther
So we can reach out to you, please check the box below:*

I'd like to receive email and/or SMS text messages from WEconnect
Should be Empty: