Find a Provider at Primary Health Medical Group

Please complete this questionnaire and a patient representative will contact you within 2-3 business days. For urgent requests, please call a clinic directly. Please note, this form is not secure. We look forward to helping you find the right care provider for you.

Todays Date*

Patient First Name*

Patient Last Name*

Patient Date of Birth*

Legal Sex*

Select

Mailing Address*

City*

State*

Zip Code*

Phone Number*

Phone

Email Address*

What type of insurance do you have?*

Please note that we do not accept Molina or Humana insurance. If you have more than one insurance, please select all insurance plans.

Pediatric Medicaid (patient under 18)

Adult Medicaid (patient 18 or older)

Medicare

Tricare (Select or Reserve Plans)

Tricare Prime Plans

Commercial (Blue Cross, Anthem, Regence, UnitedHealthcare, Aetna, Cigna, Select Health, Pacific Source etc.)

No insurance/Self-Pay

Other

Do you prefer a male or female provider?*

Female

Male

No preference

What service do you need?*

Please describe any conditions you currently have and the services you would like to receive. For example: "I am hoping to get a referral to a pain specialist." "I would like a family practice provider to manage my diabetes." "I need a provider to prescribe birth control." If you have preferred days of the week for appointments, please list those as well. This information helps us find the best fit for you!

Send me a copy of my responses