Looking for assistance?

Let us know how we can help. After you complete the form one of our trusted care coordinators will be in touch within two business days.

Confidentiality - the information you provide to Included Health will remain confidential and is never shared with your employer.

Name *
Please enter the name you'd like us to call you. We do not require your legal name and will only ask for it if it's necessary for supporting a care request (such as booking an appointment for you!)
First Name*

Last Name*
Which company do you work for? *


This request is for... *
Myself
My child
My partner or spouse


If you are looking for a provider, what kind of provider(s) would you like to see within the next 2-3 months? *
Cardiologist
Chiropractor
Dentist
Dermatologist
Dietitian
Endocrinologist
Esthetician
Fertility Clinic
Gastroenterologist
Infectious Disease
OB/GYN
Optometrist
Pediatrician
Physical Therapist
Plastic Surgeon
Primary Care
Psychiatrist
Therapist
Urologist
Vocal Coach
N/A
Other (please specify)


Tell us more about your request. If you are not looking for a provider, how can we support you? If you are looking for a provider, what is important to you about the provider(s) you are looking for? *
Please be as specific as possible. Tell us about you, the type of care you are looking for, the type of assistance you need, and any other important information.


How quickly are you looking for care or assistance?: *






Telehealth vs in-person preference: *
Given Covid-19, we want to understand your preferences. We understand some doctor appointments cannot be conducted via, Telehealth, so for those we will find in-person options.






How would you describe your relationship to your insurance plan sponsor? *
I am the primary plan holder
I am a dependent (child)
I am a dependent (partner)
N/A


Which insurance carrier and plan type do you have? *
Insurance Carrier (e.g. Aetna, BCBS, Cigna, Kaiser, United, etc.)
Plan Type (e.g. EPO, HMO, POS, PPO, HDHP)


In what state are you located? *


In what city are you located? *

What is your zip code? *

Travel Radius or Preferred Areas *
Are there specific towns, parts of cities, neighborhoods, and/or a travel radius in miles or minutes that you want us to limit your search to?


What are your pronouns? *
He/Him/His
She/Her/Hers
They/Them/Theirs
Ze/Hir/Hirs
My Pronouns Are Not Listed


As a member of the LGBTQ+ Community, please tell us how you identify. *
Please select all that apply
Bisexual
Gay
Lesbian
Cisgender
Intersex
Queer
Transgender
Transgender Female
Transgender Male
Non-Binary
Gender Fluid
Pansexual
Asexual
Heterosexual
Parent / Caregiver of LGBTQ+ youth
My identity is not listed


How would you describe yourself? *
White
Hispanic or Latinx
Black or African American
American Indian or Alaskan Native
Asian
Native Hawaiian or other Pacific islander
Prefer not to say
Other (please specify):


How would you like us to contact you back? *




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By submitting this form you are consenting to disclosing your personal information for purposes of receiving our services. For more information, please read our Terms of Service, which can be found at the bottom of this page.