Website MMU Appt Request

What is your preferred language?*

EnglishSpanishOther

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is this also the address where you live?

YesNo

Physical / Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you have health insurance?*

YesNo

What type of insurance do you have?*

Medicaid (Oregon Health Plan or Washington Apple Health)Other

Front of Insurance Card

Back of Insurance Card

Medicaid Member ID

Name of Insurer*

Group ID # (if applicable)

Member ID #*

Subscriber Information*

NameDate of BirthRelationship to Patient

Claims Address (Usually on the back of your insurance card):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

When did your insurance start?

Date

Are you the insurance subscriber?*

YesNoUnsure

What is the insurance subscriber's name?*

Subscriber's date of birth

What is the subscriber's relationship to you?*

Who is the responsible party / guarantor (person who's name will be on your billing account)?*

Registration Information