Please ensure all info entered into this form is accurate. If errors are made on this form it can delay the processing time of your application.
Please ensure the phone number and email address you provide is current and accurate. These are the only methods of communication we have in the event we need to contact you about your application process.
Once you pay for this service it is non-refundable. Once you speak with the Dr we have to get the forms filed in a timely mannor according to the law. That is why accuracy on this form and good contact information is important.
If you currently do not have a poral account we will have to make one for you. Your email address will be your user name. You will have to be able to confirm your email address durring this process. This is another example of why being available for contact is important.
Once you finish this process today, confirm your email and televisit with the doctor there is nothing you need to do but wait for you approval email from the DHHS.
Upon completion and submission of this form you will be redirected to our doctor's website (The Green Pot Clinic) where you can set your appointment to speak with the doctor, at your convience, via a Televisit appointment.
The fees quoted below cover ALL your state medical paitent fees + the filing fees for your portal work. You will be required to pay the doctor (currently $75) for his services at the time of setting your virtual appointment.
If you have any questions or concerns before the process or during the process feel free to reach out any time. 417-454-4840 (Mon-Sat 11am-7pm) or email@example.com