Network Gap Service Inquiry

Network Gap Service Inquiry

We are currently operating on a waitlist basis. To get your spot on the list, fill out this form fully.
Full Name*
Date of Birth*

MonthDayYear
Date
Who is your health insurer?*
What is your procedure?*
Who is your medical provider?*
How did you hear about Paxos?
Please acknowledge that we cannot guarantee any specific outcome of your case, should you move forward with the service.*

Yes, I acknowledge
This process will involve a good amount of work on your end to fetch the necessary information. (It's less work that doing it without the tool, but it still will take hours). Are you (or someone supporting you) open to that?*

YesNo
This process will require you to use general technology like online portals, online forms, phone calls, etc. Are you (or someone supporting you) able to do that?*

YesNo
How ready are you to proceed?*

Immediately ready (when I’m off the waitlist), no questionsInterested, but I have questionsInterested, but unsureI'm not interested
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