Appointment Assistance Request Form

First Name *

Last Name *

Member ID# *

Best phone number to reach you *

Your email address *

What type of provider or specialist do you need?

If you want an appointment with a specific provider, please give their first and last name.

Please provide your location (the address where you are currently living)

Do you need help setting up a ride for healthcare visits? * Yes No

Have you already contacted us to ask for help making an appointment? * Yes No

If yes, please give the date you contacted Member Services. (DD/MM/YYYY)

You can make a formal complaint. This is also called “filing a grievance.”

If you want to file a grievance, check the box below. I want to file a grievance