Welcome to Chaim Medical Resource
For urgent matters that need immediate assistance please call us at (718) 492 8700.
Patient Intake Form
Relationship
*
I am the patient
I am reaching out on behalf of the patient
Patient gave consent to reach out
*
Please enter patient's Information
Name
*
First Name
Last Name
Legal Name
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Type
*
Please Select
Home
Mobile
Other
Email
example@example.com
Health Insurance
*
Please Select
1199
AARP Medicare
Aetna
Affinity
AgeWell NY
Ambetter
Amerigroup
Amerihealth
Anthem BCBS
Bankers Fidelity Medicare
BCBS of Massachusetts
Blue Cross Blue Shield FEP
Blue Cross Blue Shield of Illinois
Bupa International Insurance
California Blue
Capital District Physician's Health Plan CDPHP
CareConnect
Carefirst BCBS
Cigna
Compass Insurance Services
Compass Student Insurance
Connecticare
Delta Dental
Deltacare Dental HMO
Emblemhealth
Empire BCBS
EPIC Elderly Pharmaceutical Insurance Coverage
Excellus BCBS
Fidelis
Florida Blue
GEHA Government Employees Health Association
GHI
GHI Plan for NYC Employees
Globe Life
GlobeCare Medicare
Guardian
Hamaspik Choice
Health First
Healthplus
HealthShare
HIP
Horizon
Hudson Health
Humana
Kaiser Permanente
Kupat Holim
LA Care
Liberty Healthshare
Magnacare
MBP Health
Medicare
MediChoice
Meridian Health
Metlife
Metroplus
MVP
New York Life Disability
Nippon Life
Optima Health
Oscar
Oxford UHC
Paramount
PHCS
Premera Blue Cross Blue Shield
Premier Option Plus
Principal
Priority Partners Maryland Insurance
Qualcare
Sedgwick
Sun Life Financial
Traditional Medicaid
TransAmerica
TRICARE Select
Tugo Travel Insurance
UCC, PBUCC Pension Board United Church and Christ
UHC Golden Rule PPO
United American Life Insurance
United Concordia
United Health Care
United Refuah Healthshare
Village Care
Wellcare NJ
WellPoint Maryland Insurance
Worker's Compensation
No Insurance
Other
Please explain
*
Plan Type
Community Plan/Medicaid
Private Pay
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Postal / Zip Code
Please enter your Information
Name
*
First Name
Last Name
Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Relationship to Patient
*
Please Select
Parent
Grandparent
Spouse
Sibling
Child
Other
How Can We Help:
Please enter the reason for your call
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Please provide details about your condition such as medical history, symptoms, doctors you have visited, etc.
*
If this is a time-sensitive matter that requires attention in the next 24 hours, please explain below. Otherwise, it may take up to two business days to receive a return call.
Medical Documents
To assist you in the most efficient way possible, please submit relevant reports, documents, or test results. (Or fax to 845 492-8707.)
Browse Files
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Please check off If you would like us to contact you for your login info to your patient portal/ My chart, or if you need assistance creating one.
Acknowledgment, Authorization, and Waiver
Please Note:
We do not assist with referrals to: Mental Health Professionals, Physical/Occupational Therapists, Chiropractors, Rehabs, General Dentistry, Basic Ophthalmology including Lasik for vision correction and vision therapy, Low-risk OB, General Practitioners, Pediatricians, Internists, and PCPs.
Required
*
I understand Chaim Medical Resource is an organization providing support and guidance in navigating your healthcare challenges. However, we are not healthcare providers and do not provide medical advice, diagnosis, or treatment. Therefore, you will not have a physician-patient relationship with us the way you do with your physicians. The advice given is for informational purposes and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with specific clinical questions you may have regarding your medical condition or treatment. Do not disregard professional medical advice or delay in seeking it because of something you have heard from the organization. Chaim Medical Resource is also neither an insurance broker, insurance underwriter, insurer, reinsurer, reinsurance intermediary, payor, health maintenance organization or other managed care company, health or employee benefit plan or third-party administrator, fiduciary or plan administrator and is not responsible for reimbursing any health care provider for services provided to you.
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