Help Me Find a Provider

Help Me Find a Provider
If you do not currently have a primary care provider, or would like to find a new provider, please take a moment to fill out this form. A Good Samaritan representative will then contact you within three business days to help you get set up with a new provider.
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Have you previously been a patient of Good Samaritan Physician Network?

YesNo
What area of providers are you interested in? (Descriptions below)

Internal Medicine: Internal medicine is the medical specialty dealing with the prevention, diagnosis, and treatment of internal diseases in adults.
Family Practice: A medical specialty within primary care that provides continuing and comprehensive health care for the individual and family across all ages, genders, diseases, and parts of the body.
Pediatrics: A medical specialty dealing with the health and medical care ofinfants, children, and adolescents from birth up to the age of 18.
Select Area

Internal MedicineFamily PracticePediatricsI don't know
I prefer a:

DoctorNurse PractitionerPhysician AssistantResidentDoesn't Matter
I prefer a:

MaleFemale
What is the best time of day to reach you? (Select all that apply)

8 a.m. to 10 a.m.10 a.m. to NoonNoon to 2 p.m.2 p.m. to 3 p.m.3 p.m. to 5 p.m.
Comments
Thank you for choosing Good Samaritan as your healthcare provider.

If you are having a medical emergency, call 911 or emergency medical help.
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Help Me Find a Provider

What area of providers are you interested in? (Descriptions below)