Primary Care Request Form

Primary Care Request Form

Please fill out this secure form to request a new patient visit at CHA.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
How did you learn about CHA Primary Care?
Would you like to include other minor children in this new patient request?

YesNo
If yes, please list the family member names:
Do you have health insurance?*

YesNo

If yes, what type of health insurance do you have?*

TuftsBlue Cross Blue Shield of MAHarvard PilgrimMass HealthOther
*Please note the following insurances are NOT accepted by CHA:

• BE Healthy Partnership

• BMC WellSense (Beth Israel Lahey Health {BILH}, Boston Children’s ACO, Care Alliance, CarePlus, Community Alliance, Essential MCO, East Boston ACO, HealthNet, Medicare Advantage, Mercy Alliance, NH, Senior Care Options, Signature Alliance or Southcoast Alliance)

• Community Care Cooperative (C3)

• Elder Service Plan at Uphams

• Fallon (365 Plan, Atrius Healthcare, Berkshire Collaboration Care Plus, HMO, NaviCare, PPO, Senior Plan or Wellforce Care Plan)

• Health New England Plus

• Humana (EPO, POS or PPO)

• Mass General Brigham ACO, LLC

• Mass Health PCC

• Mass Health Revere Health Choice

• Steward Health Choice

• Tufts Together (HealthPlan or with UMass)

• WellCare Medicare Advantage
What is your insurance policy number?*
What is your group ID number (if applicable)?
Are you the primary policy holder?*

YesNo
If not, please list the name of the primary policy holder*
Please list your name as it appears on your insurance card.*

First NameLast Name
If able, please upload two pictures (front and back) of your Health Insurance Card

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