Information Request - NYS of Health Plans

Information Request for KBellbenefits, LLC

Please complete all of the application fields below. An "*" indicated a required field.

Click SUBMIT button at the bottom when finished. Thank you

First & Last Name (only one person per information request from please)

Multi-line address

Country/Region

Address

City

Zip / Postal code

County

Preferred Phone

When would you like your new medical healthcare plan to start or change?

Do you have Medicaid provided by your state?

Yes

Are you a US Veteran?

PHYSICIANS

OPTIONAL: Upload a document listing ALL your physicans

List medical providers & specialties (skip if you have uploaded a file)

Primary Care Physician

List their specialty:

Primary Care Physician (PCP)

1 - DDS:

1 - List their specialty:

Dentist

2 - Doctor:

2 - List their specialty:

3 - Doctor:

3 - List their specialty:

4 - Doctor:

4 - List their specialty:

5 - Doctor:

5 - List their specialty:

6 - Doctor:

6 - List their specialty:

7 - Doctor:

7 - List their specialty:

List additional physicians and their specialty in the text field below

MEDICATIONS

Your preferred pharmacy name and location:

OPTIONAL: Upload a document listing ALL of your prescription medications.

List ONLY prescription medications, no Over-The-Counter (skip if you have uploaded a file)

1 - Drug name - enter NONE if no Rx

1 - Dose (mg, tab, ml, etc)

1 - How often?

2 - Drug name

2 - Dose

2 - How often?

3 - Drug name

3 - Dose

3 - How often?

4 - Drug name

4 - Dose

4 - How often?

5 - Drug name

5 - Dose

5 - How often?

6 - Drug name

6 - Dose

6 - How often?

7 - Drug name

7 - Dose

7 - How often?

8 - Drug name

8 - Dose

8 - How often?

9 - Drug name

9 - Dose

9 - How often?

List additional drugs, dose, and frequency of intake in the text field below

Other concerns:

Click the SUBMIT button below