Appointment Request Form
Guardian Full Name
*
Mr.
Mrs.
Miss.
Prefix
First Name
Last Name
Client Full Name
Mr.
Mrs.
Miss.
Prefix
First Name
Last Name
Date of Birth (DOB)
*
-
Month
-
Day
Year
Date
Insurance Type:
*
Absolute Total Care
Anthem Blue Cross
Behavioral Health Systems
Blue Choice Medicaid Managed Care
BCBS of South Carolina
CIGNA Behavioral Health
CIGNA Health Plan - HMO
CIGNA - PPO
First Sun EAP Alliance, INC
Magellan Health Services
Morneau & Shepell
PHCS/Cigna
Planned Administrators Inc.
Select Health of South Carolina
South Carolina Medicaid
Humana Inc.
Tricare East
UnitedHealthcare/ OPTUM
***Other***
Contact Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you find Points of Origin?
*
What would you like support with?
*
What is the best time to contact you?
*
Please Select
Morning (9am-12pm)
Afternoon: (1pm-3pm)
Late afternoon (3pm-5pm)
Preferred method of contact?
*
Please Select
Email
Phone
Text
Please verify that you are human
*
Submit
Should be Empty: