This form is not encrypted. Please do not include any personal identifying information such as your DOB, SSN, Medicaid ID or any medical information. It is our policy and duty as a healthcare entity to not use email when sharing confidential information. We will respond to all inquiries within one business day.
As a final reminder: Please do not submit any confidential or sensitive information For example: Social Security Number (SSN), Medicaid or Medicare ID, Treatment Information or something that can identify you.