AVEMA telehealth
AVEMA telehealth encounter number:
Today's date
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Month
-
Day
Year
Date
Do you belong to one of these medical groups?
*
Kaiser
High Desert Medical Group
Sierra Medical Group
None of the above
We're sorry, but we cannot offer telehealth services to members of your health plan. Please call your plan to ask about covered telehealth services.
Is patient under 18?
*
No
Yes
Patient first name
*
Patient middle name
Patient last name
*
Reason for visit
*
Date of birth
*
Please select a month
January
February
March
April
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Month
Please select a day
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Day
Please select a year
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1921
1920
Year
Gender
*
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Phone Number
*
This is for only communicating with you about your appointment. Your number will not be used for marketing purposes.
Social security number
Required for billing insurance.
Guardian first name
*
Guardian last name
*
Guardian date of birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Guardian gender
*
Male
Female
Guardian address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Guardian phone number
*
This is for only communicating with you about this appointment. Your number will not be used for marketing purposes.
Guardian social security number
Required for billing insurance.
Insurance plan
*
Anthem
Blue Cross
Blue Shield
Cigna
Health Net
Humana
LA Care
Medi-cal
Medicare
Other (we cannot accept Kaiser, HDMG, or SMG patients)
You will need to upload EITHER a picture of the front and back of your insurance card, or complete the fields below.
Can you take or upload a picture of your insurance card?
*
Yes
No, I will enter the information myself
Front of insurance card
Back of insurance card
Name of insured (as appears on card)
Insurance ID
Insurance group number
Insurance plan address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance phone number (for providers)
Patient or guardian signature
Submit
Should be Empty: