REQUEST HELP Phone 718-492-8700 Email info@cmresource.org Fax + 1 845-363-4394 Brooklyn 3611 14th Avenue, Suite 347 Brooklyn NY 11218 Monroe 68 Seven Springs Mountain Rd. #101 Monroe, New York 10950 Monsey 95 Chestnut Ridge Rd Montvale, NJ 07645 Name Email Phone Message Send Intake Form Welcome to Chaim Medical Resource For urgent matters that need immediate assistance please call us at (718) 492 8700. Patient Intake Form Relationship* I am the patientI am reaching out on behalf of the patient Patient gave consent to reach out* Please enter patient's Information Name* First NameLast Name Legal Name First NameLast Name If different from above Date of Birth* -Month -DayYearDate Phone Number* Please enter a valid phone number. Phone Type * Please Select Home Mobile Other Email example@example.com Health Insurance* Please Select 1199 AARP Medicare Aetna Affinity AgeWell NY Ambetter Amerigroup Amerihealth Anthem BCBS Bankers Fidelity Medicare BCBS of Massachusetts Blue Cross Blue Shield FEP Blue Cross Blue Shield of Illinois Bupa International Insurance California Blue Capital District Physician's Health Plan CDPHP CareConnect Carefirst BCBS Cigna Compass Insurance Services Compass Student Insurance Connecticare Delta Dental Deltacare Dental HMO Emblemhealth Empire BCBS EPIC Elderly Pharmaceutical Insurance Coverage Excellus BCBS Fidelis Florida Blue GEHA Government Employees Health Association GHI GHI Plan for NYC Employees Globe Life GlobeCare Medicare Guardian Hamaspik Choice Health First Healthplus HealthShare HIP Horizon Hudson Health Humana Kaiser Permanente Kupat Holim LA Care Liberty Healthshare Magnacare MBP Health Medicare MediChoice Meridian Health Metlife Metroplus MVP New York Life Disability Nippon Life Optima Health Oscar Oxford UHC Paramount PHCS Premera Blue Cross Blue Shield Premier Option Plus Principal Priority Partners Maryland Insurance Qualcare Sedgwick Sun Life Financial Traditional Medicaid TransAmerica TRICARE Select Tugo Travel Insurance UCC, PBUCC Pension Board United Church and Christ UHC Golden Rule PPO United American Life Insurance United Concordia United Health Care United Refuah Healthshare Village Care Wellcare NJ WellPoint Maryland Insurance Worker's Compensation No Insurance Other Please explain* Plan Type Community Plan/MedicaidPrivate Pay Address Street Address Street Address Line 2 CityState / Province Postal / Zip Code * Street Address Street Address Line 2 CityState / Province Postal / Zip Code Postal / Zip Code Should the patient be contacted?* YesNo Phone Number* Please enter a valid phone number. Phone Type * Please Select Home Mobile Other Please enter your Information Name* First NameLast Name Home Phone Number * Please enter a valid phone number. Cell Phone Number * Please enter a valid phone number. Email example@example.com Relationship to Patient* Please Select Parent Grandparent Spouse Sibling Child Other How Can We Help: Please enter the reason for your call* Please provide details about your condition such as medical history, symptoms, doctors you have visited, etc.* If this is a time-sensitive matter that requires attention in the next 24 hours, please explain below. Otherwise, it may take up to two business days to receive a return call. Medical Documents If you have any relevant reports, documents, labs, doctors' notes, etc. please upload them here. (Or fax to 845 492-8707.) Browse FilesDrag and drop files here Choose a file Drop files here to uploadBrowse FilesDrag and drop files here Choose a file Cancelof Cancelof Please check off If you would like us to contact you for your login info to your patient portal/ My chart, or if you need assistance creating one. Acknowledgment, Authorization, and Waiver Please Note: We do not assist with referrals to: Mental Health Professionals, Physical/Occupational Therapists, Chiropractors, Rehabs, General Dentistry, Basic Ophthalmology including Lasik for vision correction and vision therapy, Low-risk OB, General Practitioners, Pediatricians, Internists, and PCPs. Required* I understand Chaim Medical Resource is an organization providing support and guidance in navigating your healthcare challenges. However, we are not healthcare providers and do not provide medical advice, diagnosis, or treatment. Therefore, you will not have a physician-patient relationship with us the way you do with your physicians. The advice given is for informational purposes and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with specific clinical questions you may have regarding your medical condition or treatment. Do not disregard professional medical advice or delay in seeking it because of something you have heard from the organization. Chaim Medical Resource is also neither an insurance broker, insurance underwriter, insurer, reinsurer, reinsurance intermediary, payor, health maintenance organization or other managed care company, health or employee benefit plan or third-party administrator, fiduciary or plan administrator and is not responsible for reimbursing any health care provider for services provided to you. Signature* Clear Print name:* Submit Thank you for submitting. We will get back to you as soon as possible. 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