Submit a request – Oria Health

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What's the nature of your billing question?(optional)

Patient's first and last name(optional)

ex: Maria Brown

Patient or patient guardian's phone number(optional)

ex: 2545551234

Patient's date of birth(optional)

MM/DD/YYYY format (ex: 01/13/2003)

Will you be using insurance?

Note: if you are using insurance, you must upload a picture of your insurance card

Do you have a secondary insurance?

If so, upload a picture of your secondary insurance card as well.

What's the nature of your prescription request?(optional)

The nature of your request?(optional)

What are you looking to do?(optional)

What type of service/appointment?(optional)

What type of psychological evaluation service/appointment is this regarding?(optional)

What type of psychological evaluation?(optional)

What type of medication service/appointment is this regarding?(optional)

What type of therapy service/appointment is this regarding?(optional)

Provider preference(optional)

Are you reaching out about multiple appointments or services?(optional)

Note: If yes, please list each service and describe what is needed in the Description field at the bottom

What's the best way to reach you?(optional)

How did you hear about us?

What was/is the date of the service in question?(optional)

Please list the name/dosage of each medication(optional)

Do you have a follow up appointment scheduled?(optional)

Are you the patient or are you a representative of the patient?(optional)

Have you already filled out a Release of Information form?(optional)

Terms and Conditions Signature(optional)

Input your full legal name after reading our {terms and conditions|https://www.oria.health/terms-conditions-08-19-2024} to show you understand and agree to the terms outlined.

Privacy Policy Signature(optional)

Input your full legal name after reading our {privacy policy|https://www.oria.health/privacy-practices-8-19-2024} to show you understand and agree to the terms outlined.

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Description

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