MyEzMed Telehealth Appointment Request Form

MyEzMed Telehealth Appointment Request Form

Please complete your information. Once we receive your request, a care coordinator will reach out to you personally to guide next steps and help coordinate your care. We look forward to supporting you in your care.
Name

First NameLast Name
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
What is your primary concern?

Other
Once we receive your information, a MyEzMed care coordinator will reach out to you personally to guide next steps and help coordinate care. There’s nothing else you need to do right now — we’ll take it from here.
Medicare Insurance Policy Number
Supplemental Insurance Name
Supplemental Insurance Policy Number
Take Photo of Insurance Card(s) Using Your Phone Tap to open your camera and take a picture of your card. You may upload or take one photo at a time. If needed, take or upload a second photo for the back of the card.
Care Coordination & Information Confirmation

By signing below, you authorize MyEzMed to use the information provided in this form to help coordinate your care. You confirm that the information you’ve provided is accurate to the best of your knowledge.
Patient Signature
Date
Please choose your preferred appointment time(s):
Please choose your preferred appointment day(s):
Should be Empty: