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HIPAA
Compliance
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First Name
Last Name
Email
Mobile Phone
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2
Do You have a NYSHIP Health Insurance Plan Coverage?
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NYSHIP EMPIRE PLAN
NYSHIP Excelsior Plan
NYSHIP Student Plan
No/other
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3
Unique ID
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4
Employer
Enter your employer or your school if you are a student
Employer /School
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Employed
Unemployed
Student
Employed
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Employed
Unemployed
Student
Employment Status
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5
Would you like to enter your insurance details now?
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No, I would prefer to first schedule my appointment
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