What state are you located in?

  • [[{"field_id":5600,"subrules":{"field_id":5599,"value":"Minnesota","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":5601,"subrules":{"field_id":5599,"value":"Arizona","operator":"Match"}}],[{"field_id":5601,"subrules":{"field_id":5599,"value":"Arkansas","operator":"Match"}}],[{"field_id":5601,"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":5601,"subrules":{"field_id":5599,"value":"Florida","operator":"Match"}}],[{"field_id":5601,"subrules":{"field_id":5599,"value":"Georgia","operator":"Match"}}],[{"field_id":5601,"subrules":{"field_id":5599,"value":"Hawaii","operator":"Match"}}],[{"field_id":5601,"subrules":{"field_id":5599,"value":"Idaho","operator":"Match"}}],[{"field_id":5601,"subrules":{"field_id":5599,"value":"Illinois","operator":"Match"}}],[{"field_id":5601,"subrules":{"field_id":5599,"value":"Indiana","operator":"Match"}}],[{"field_id":5601,"subrules":{"field_id":5599,"value":"Iowa","operator":"Match"}}],[{"field_id":5601,"subrules":{"field_id":5599,"value":"Kansas","operator":"Match"}}],[{"field_id":5601,"subrules":{"field_id":5599,"value":"Kentucky","operator":"Match"}}],[{"field_id":5601,"subrules":{"field_id":5599,"value":"Louisiana","operator":"Match"}}],[{"field_id":5601,"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":5601,"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":5601,"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":5601,"subrules":{"field_id":5599,"value":"Wisconsin","operator":"Match"}}],[{"field_id":5601,"subrules":{"field_id":5599,"value":"Wyoming","operator":"Match"}}]]

Are you using Medicare B for this visit?

    • [[{"field_id":5668,"subrules":{"field_id":5600,"value":"Yes","operator":"Match"}}],[{"field_id":5602,"subrules":{"field_id":5600,"value":"No","operator":"Match"}}]]

Are you using medical insurance for the visit?

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

Please select your insurance carrier:

    • [[{"field_id":5668,"subrules":{"field_id":5603,"value":"AARP","operator":"Match"}}],[{"field_id":5668,"subrules":{"field_id":5603,"value":"Aetna","operator":"Match"}}],[{"field_id":5668,"subrules":{"field_id":5603,"value":"Americas PPO","operator":"Match"}}],[{"field_id":5668,"subrules":{"field_id":5603,"value":"BCBS","operator":"Match"}}],[{"field_id":5668,"subrules":{"field_id":5603,"value":"Champ VA","operator":"Match"}}],[{"field_id":5668,"subrules":{"field_id":5603,"value":"Cigna","operator":"Match"}}],[{"field_id":5668,"subrules":{"field_id":5603,"value":"GEHA","operator":"Match"}}],[{"field_id":5668,"subrules":{"field_id":5603,"value":"HealthPartners","operator":"Match"}}],[{"field_id":5668,"subrules":{"field_id":5603,"value":"Humana","operator":"Match"}}],[{"field_id":5668,"subrules":{"field_id":5603,"value":"Medica","operator":"Match"}}],[{"field_id":5668,"subrules":{"field_id":5603,"value":"Medicare","operator":"Match"}}],[{"field_id":5668,"subrules":{"field_id":5603,"value":"Multiplan","operator":"Match"}}],[{"field_id":5668,"subrules":{"field_id":5603,"value":"Medicaid-MN","operator":"Match"}}],[{"field_id":5668,"subrules":{"field_id":5603,"value":"Optum VA","operator":"Match"}}],[{"field_id":5668,"subrules":{"field_id":5603,"value":"Solartehealth","operator":"Match"}}],[{"field_id":5668,"subrules":{"field_id":5603,"value":"Surest","operator":"Match"}}],[{"field_id":5668,"subrules":{"field_id":5603,"value":"Tricare East","operator":"Match"}}],[{"field_id":5668,"subrules":{"field_id":5603,"value":"Tricare for Life","operator":"Match"}}],[{"field_id":5668,"subrules":{"field_id":5603,"value":"Tricare West","operator":"Match"}}],[{"field_id":5668,"subrules":{"field_id":5603,"value":"United Health Care","operator":"Match"}}],[{"field_id":5668,"subrules":{"field_id":5603,"value":"Ucare","operator":"Match"}}],[{"field_id":5668,"subrules":{"field_id":5603,"value":"UMR\n","operator":"Match"}}]]

What type of visit do you want?

Are you using Medicare B for this visit?

    • [[{"field_id":14863,"subrules":{"field_id":5601,"value":"No","operator":"Match"}}]]

Please select your insurance carrier:

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: