Appointment Request Form
Your Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Your Email
example@example.com
Your Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Provider: Please select your primary insurance provider. If you do not see your insurance provider listed, or you are unsure, please call our office scheduler at, 405-424-5426.
Please Select
AETNA
AETNA BETTER HEALTH
BLUE ADVANTAGE PPO
BLUE CHOICE PPO
BLUE PREFFERED PPO
BLUELINCS HMO (MUST HAVE A REFERRAL)
BLUE PLAN 65
BLUE TRADITIONAL
BLUE MEDICARE ADVANTAGE HMO & PPO
CIGNA
COMMUNITY CARE HMO (MUST HAVE A REFERRAL)
CORVEL
COVENTRY/FIRST HEALTH
DOL
EVOLUTIONS
GALAXY
HEALTHCARE HIGHWAYS/OHN
HEALTHCHOICE
HEALTHSMART
HUMANA CHOICE CARE
HUMANA CHOICE CARE MEDICARE ADVANTAGE PPO
HUMANA HALTHY HORIZONS IN OKLAHOMA
INTEGRIS HEALTH PARTNERS (IHP)
MEDICAID / SOONERCARE
MEDICARE
MEDICARE RAILROAD
MULTIPLAN / PHCS
NPPN
OSMA HEALTH
PACIFICARE
PREFERRED COMMUNITY CHOICE (PCC)
ROCKPORT
SECURE HORIZONS
TRICARE PRIME (AUTHORIZATION REQUIRED)
TRICARE STANDARD
TRIWEST
USA MCO
WORKNET
OTHER
Has the joint you are having problems with already been replaced?
Yes
No
Patient Status. Are you an existing or new patient?
Existing Patient
New Patient
What day/time of the week would you like to have your appointment?
Do you have a cardiologist
Yes
No
Who is your cardiologist?
Reason for Appointment:
*
Submit
Should be Empty: