What state are you located in?

  • [[{"field_id":"5600","subrules":{"field_id":"5599","value":"Minnesota","operator":"Match"}}],[{"field_id":"5667","subrules":{"field_id":"5599","value":"Wisconsin","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"Alabama","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"Alaska","operator":"Match"}}],[{"field_id":"6684","subrules":{"field_id":"5599","value":"Arizona","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"Arkansas","operator":"Match"}}],[{"field_id":"6684","subrules":{"field_id":"5599","value":"California","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"Colorado","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"Connecticut","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"Delaware","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"District of Columbia","operator":"Match"}}],[{"field_id":"6684","subrules":{"field_id":"5599","value":"Florida","operator":"Match"}}],[{"field_id":"6684","subrules":{"field_id":"5599","value":"Georgia","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"Hawaii","operator":"Match"}}],[{"field_id":"6684","subrules":{"field_id":"5599","value":"Idaho","operator":"Match"}}],[{"field_id":"6684","subrules":{"field_id":"5599","value":"Illinois","operator":"Match"}}],[{"field_id":"6684","subrules":{"field_id":"5599","value":"Indiana","operator":"Match"}}],[{"field_id":"6684","subrules":{"field_id":"5599","value":"Iowa","operator":"Match"}}],[{"field_id":"6684","subrules":{"field_id":"5599","value":"Kansas","operator":"Match"}}],[{"field_id":"6684","subrules":{"field_id":"5599","value":"Kentucky","operator":"Match"}}],[{"field_id":"6684","subrules":{"field_id":"5599","value":"Louisiana","operator":"Match"}}],[{"field_id":"6684","subrules":{"field_id":"5599","value":"Maine","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"Maryland","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"Massachusetts","operator":"Match"}}],[{"field_id":"6684","subrules":{"field_id":"5599","value":"Michigan","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"Mississippi","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"Missouri","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"Montana","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"Nebraska","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"Nevada","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"New Hampshire","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"New Jersey","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"New Mexico","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"New York","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"North Carolina","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"North Dakota","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"Ohio","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"Oklahoma","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"Oregon","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"Pennsylvania","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"Rhode Island","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"South Carolina","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"South Dakota","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"Tennessee","operator":"Match"}}],[{"field_id":"5771","subrules":{"field_id":"5599","value":"Texas","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"Utah","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"Vermont","operator":"Match"}}],[{"field_id":"6684","subrules":{"field_id":"5599","value":"Virginia","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"Washington","operator":"Match"}}],[{"field_id":"5601","subrules":{"field_id":"5599","value":"West Virginia","operator":"Match"}}],[{"field_id":"6684","subrules":{"field_id":"5599","value":"Wyoming","operator":"Match"}}]]

Are you using Medicare B for this visit?

  • [[{"field_id":"5604","subrules":{"field_id":"5600","value":"Yes","operator":"Match"}}],[{"field_id":"5602","subrules":{"field_id":"5600","value":"No","operator":"Match"}}]]

Are you using Medicare B for this visit?

  • [[{"field_id":"5668","subrules":{"field_id":"5667","value":"Yes","operator":"Match"}}],[{"field_id":"5666","subrules":{"field_id":"5667","value":"No","operator":"Match"}}]]

Are you using Medicare B for this visit?

  • [[{"field_id":"6682","subrules":{"field_id":"5601","value":"No","operator":"Match"}}]]

Are you using Medicare B for this visit?

  • [[{"field_id":"6686","subrules":{"field_id":"6684","value":"No","operator":"Match"}}]]

Are you using medical insurance for the visit?

  • [[{"field_id":"5603","subrules":{"field_id":"5602","value":"Yes","operator":"Match"}}]]

Are you using medical insurance for the visit?

  • [[{"field_id":"5663","subrules":{"field_id":"5666","value":"Yes","operator":"Match"}}]]

Please select your insurance carrier:

  • [[{"field_id":"5668","subrules":{"field_id":"5663","value":"BCBS","operator":"Match"}}],[{"field_id":"5668","subrules":{"field_id":"5663","value":"Aetna","operator":"Match"}}],[{"field_id":"5668","subrules":{"field_id":"5663","value":"Cigna","operator":"Match"}}],[{"field_id":"5668","subrules":{"field_id":"5663","value":"United Health Care","operator":"Match"}}],[{"field_id":"5668","subrules":{"field_id":"5663","value":"Medica","operator":"Match"}}],[{"field_id":"5668","subrules":{"field_id":"5663","value":"Preferred One","operator":"Match"}}],[{"field_id":"5668","subrules":{"field_id":"5663","value":"Ucare","operator":"Match"}}],[{"field_id":"5668","subrules":{"field_id":"5663","value":"HealthPartners","operator":"Match"}}],[{"field_id":"5668","subrules":{"field_id":"5663","value":"Tricare West","operator":"Match"}}],[{"field_id":"5668","subrules":{"field_id":"5663","value":"Tricare for Life","operator":"Match"}}],[{"field_id":"5668","subrules":{"field_id":"5663","value":"Humana","operator":"Match"}}],[{"field_id":"5668","subrules":{"field_id":"5663","value":"Surest","operator":"Match"}}],[{"field_id":"5668","subrules":{"field_id":"5663","value":"AARP","operator":"Match"}}],[{"field_id":"5668","subrules":{"field_id":"5663","value":"Champ VA","operator":"Match"}}],[{"field_id":"5668","subrules":{"field_id":"5663","value":"GEHA","operator":"Match"}}],[{"field_id":"5668","subrules":{"field_id":"5663","value":"Multiplan","operator":"Match"}}],[{"field_id":"5668","subrules":{"field_id":"5663","value":"Americas PPO","operator":"Match"}}],[{"field_id":"5668","subrules":{"field_id":"5663","value":"Optum VA","operator":"Match"}}]]

Please select your insurance carrier:

  • [[{"field_id":"5604","subrules":{"field_id":"5603","value":"BCBS","operator":"Match"}}],[{"field_id":"5604","subrules":{"field_id":"5603","value":"Aetna","operator":"Match"}}],[{"field_id":"5604","subrules":{"field_id":"5603","value":"Cigna","operator":"Match"}}],[{"field_id":"5604","subrules":{"field_id":"5603","value":"United Health Care","operator":"Match"}}],[{"field_id":"5604","subrules":{"field_id":"5603","value":"Medica","operator":"Match"}}],[{"field_id":"5604","subrules":{"field_id":"5603","value":"Preferred One","operator":"Match"}}],[{"field_id":"5604","subrules":{"field_id":"5603","value":"Ucare","operator":"Match"}}],[{"field_id":"5604","subrules":{"field_id":"5603","value":"Medicaid-MN","operator":"Match"}}],[{"field_id":"5604","subrules":{"field_id":"5603","value":"HealthPartners","operator":"Match"}}],[{"field_id":"5604","subrules":{"field_id":"5603","value":"Tricare West","operator":"Match"}}],[{"field_id":"5604","subrules":{"field_id":"5603","value":"Tricare for Life","operator":"Match"}}],[{"field_id":"5604","subrules":{"field_id":"5603","value":"Humana","operator":"Match"}}],[{"field_id":"5604","subrules":{"field_id":"5603","value":"Surest","operator":"Match"}}],[{"field_id":"5604","subrules":{"field_id":"5603","value":"AARP","operator":"Match"}}],[{"field_id":"5604","subrules":{"field_id":"5603","value":"Champ VA","operator":"Match"}}],[{"field_id":"5604","subrules":{"field_id":"5603","value":"GEHA","operator":"Match"}}],[{"field_id":"5604","subrules":{"field_id":"5603","value":"Multiplan","operator":"Match"}}],[{"field_id":"5604","subrules":{"field_id":"5603","value":"Americas PPO","operator":"Match"}}],[{"field_id":"5604","subrules":{"field_id":"5603","value":"Optum VA","operator":"Match"}}],[{"field_id":"5604","subrules":{"field_id":"5603","value":"Solartehealth","operator":"Match"}}]]

What type of visit do you want?

What type of visit do you want?

Are you using Medicare B for this visit?

  • [[{"field_id":"5772","subrules":{"field_id":"5771","value":"No","operator":"Match"}}]]

Are you using medical insurance for the visit?

  • [[{"field_id":"5773","subrules":{"field_id":"5772","value":"Yes","operator":"Match"}}]]

Please select your insurance carrier:

Please select your insurance carrier:

Please select your insurance carrier: