Request An Appointment

This form will be sent to Wellpoint Care Network via electronic communication. I understand that electronic communication is a convenience and not appropriate for emergencies or time-sensitive issues. Additionally, I understand that the security and privacy of electronic comunication cannot be guaranteed. Further, I understand that electronic communication should not be used to transmit highly sensitive or personal information. With regard to my protected health information, I understand that Wellpoint can send unencrypted emails ONLY if I am advised of the risks. I understand electronic messages are privileged and confidential and is covered by the Electronic Communications Privacy Act, 18 U.S.C § 2510-2521. I consent to e-mail and SMS communication with Wellpoint.