How do you plan to cover services?
If you have coverage under more than one insurance plan, we will need information about all plans. If we don't have coverage information for all active plans, this can result in denied claims, a pause in services, or additional charges. If you have dual coverage through a non-Medicaid and a Medicaid (Apple Health) plan, please list the non-Medicaid plan as your primary.
(If not self)
(If applicable)
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If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.