MyEzMed Telehealth Appointment Request Form

MyEzMed Telehealth Appointment Request Form

Please complete the form below to help us better support you.
Full Name*

First NameLast Name
Address*

Street Address

Street Address 2

CityState

Zip Code
Date of Birth*

MonthDayYear
Date
Email Address
example@example.com
Mobile Phone Number*
Please enter a valid phone number.
Insurance Member ID Number (optional)
If you were sent to MyEzMed by your health plan, you may enter your member ID to help us coordinate care more efficiently.
What is your primary concern?*

AnxietyChronic PainCognitive & MemoryDepressionIsolation & LonelinessGrief & LossLife TransitionsPhobiasSleep IssuesStress ManagementSubstance AbuseOther
Please let us know what time works for you, and our team will follow up to coordinate scheduling.*
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
I do not plan to use insurance for this care.
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, including communication with other providers as needed. You confirm that the information you’ve provided is accurate to the best of your knowledge.
Patient Signature*

Clear
Date*
Should be Empty: