Gracias por su confianza en USA Vein Clinics al recomendarnos a sus pacientes. Por favor complete el siguiente formulario. Nos comunicaremos con su paciente directamente para programar su consulta. DETALLES DEL PACIENTE Nombre de pila * Apellido * Email * Teléfono del paciente Elegir la ubicación * --- Glendale Phoenix W Camelback Rd. Glendale Valley Village West Hollywood Fairfield North Haven Georgia Ave K Street Altamonte Springs Fort Myers Habana Avenue Hallandale Beach Hialeah Kissimmee Lady Lake Miami Orlando Pinellas Park Tamarac Alpharetta (Old Milton Parkway) Austell Brookhaven Decatur Kennesaw Lawrenceville Marietta Midtown Location Archer Ave. Barrington Belmont Ave. Elk Grove Village Elmwood Park Frankfort Geneva Gurnee Mundelein Naperville (Springbrook Square Dr) Northbrook Oakbrook Terrace Orland Park Plainfield Schaumburg Skokie (Village Crossing) West Ida B. Wells Drive Merrillville Overland Park Annapolis Baltimore (Locust Point) Chevy Chase Columbia Pikesville Rockville Timonium Framingham Lynn West Roxbury Woburn Maple Grove Woodbury Kansas City St. Louis Marlton Orange Tinton Falls Trenton Union City 1st Avenue Astoria Bensonhurst Bethpage Brighton Beach Broadway Bushwick Chelsea Dyckman Flatbush Fordham Forest Hills Foxhurst Graham Harlem Jackson Heights Jamaica Jerome Ave Lenox Hill Lower Manhattan Mott Haven Pennsylvania Ave Ridgewood Rochester Sheepshead Bay St. Nicholas Staten Island Stony Brook Suffern Valley Stream Washington Heights Westchester Ave. White Plains Road Yonkers Cary Mooresville Canfield Fairlawn Middleburg North Canton Altoona Erie Fox Chapel Johnstown Philadelphia Pittsburgh South Broad Street Southampton State College West Chester Wexford Mt. Pleasant Brentwood Arlington Arlington Austin Corpus Christi Flower Mound Forest Lane Fort Worth Fort Worth on S Hulen Street Garland (Firewheel) Houston Houston (River Oaks) Irving Missouri City Plano Richardson San Antonio Southlake The Woodlands Tomball Holladay Roy West Valley City Arlington (Shirlington) Chantilly Fairfax Sterling Vienna Bellevue Kent Seattle Morgantown Brookfield Kenosha Mequon Plan de seguro del paciente * —Please choose an option—AetnaAnthem Blue Cross Blue ShieldBlue Cross Blue ShieldCignaEmblemHealth (formerly known as GHI)EmblemHealth (formerly known as HIP)Empire Blue Cross Blue ShieldUnitedHealthcareUnitedHealthcare OxfordAARPAbsolute Total CareAccess Medicare (NY)Accountable Health Plan of OhioACEAdvantage HealthAdvantageMDAdvanticaAdventist HealthAdvocate Health CareAetna Better HealthAffinity Health PlanAgeWell New YorkAgile Health InsuranceAIGAlameda Alliance for HealthAlignment Health PlanAll Savers InsuranceAllegian Health PlansAllegiance Life and HealthAlliant Health PlansAllianz Worldwide CareAlohaCareAlphaCareAltaMed Senior BuenaCare (PACE)Altius (Coventry Health Care)AlwaysCareAmbetterAmerican BehavioralAmerican EldercareAmerican Healthcare AllianceAmerican Republic Insurance CompanyAmerica's 1st ChoiceAmeriGroupAmeriHealthAmeriHealth CaritasAmida CareAmish Church FundAmplifon Hearing Health CareAnthem Blue CrossAPWUArchCareArise Health PlanArizona Foundation for Medical CareArkansas Blue Cross Blue ShieldAscension HealthAssurant Employee BenefitsAssurant HealthAsuris Northwest HealthATRIO Health PlansAultcareAvera Health PlansAverde HealthAvesisAvMedBanker's LifeBanner HealthBaptist Health PlanBeacon Health Options (ValueOptions)Beaumont Employee Health PlanBeech StreetBest Choice PlusBest Life And HealthBetter Health (Florida Medicaid)Block VisionBlue Choice Health PlanBlue Cross Blue Shield Federal Employee ProgramBlue Cross Blue Shield of AlabamaBlue Cross Blue Shield of ArizonaBlue Cross Blue Shield of Florida (Florida Blue)Blue Cross Blue Shield of GeorgiaBlue Cross Blue Shield of IllinoisBlue Cross Blue Shield of KansasBlue Cross Blue Shield of Kansas CityBlue Cross Blue Shield of LouisianaBlue Cross Blue Shield of MassachusettsBlue Cross Blue Shield of MichiganBlue Cross Blue Shield of MinnesotaBlue Cross Blue Shield of MississippiBlue Cross Blue Shield of MontanaBlue Cross Blue Shield of NebraskaBlue Cross Blue Shield of New MexicoBlue Cross Blue Shield of North CarolinaBlue Cross Blue Shield of North DakotaBlue Cross Blue Shield of OklahomaBlue Cross Blue Shield of Rhode IslandBlue Cross Blue Shield of South CarolinaBlue Cross Blue Shield of TennesseeBlue Cross Blue Shield of TexasBlue Cross Blue Shield of VermontBlue Cross Blue Shield of Western New YorkBlue Cross Blue Shield of WyomingBlue Cross of IdahoBlue Cross of Northeastern PennsylvaniaBlue Shield of CaliforniaBlue Shield of Northeastern New YorkBluegrass Family Health PlanBMC HealthNet PlanBrand New DayBridgeSpanBridgeway Health SolutionsBright HealthBuckeye Health PlanCalifornia Health and WellnessCalOptimaCalPERSCalViva HealthCapital Blue CrossCapital Health PlanCare Access Health PlanCare Improvement PlusCare N' CareCare1stCareConnectCareFirst Blue Cross Blue ShieldCareMoreCareOregonCarePlus Health Plans (Florida Medicare)CareSourceCascade Health AllianceCaterpillarCBA BlueCDPHPCeltiCare Health PlanCenCal HealthCenpaticoCentennial CareCenterLight HealthcareCenters for Medicare & Medicaid ServicesCentral California Alliance for HealthCentral Health Plan of CaliforniaCentury Healthcare - CHCCHAMPVAChildren's Community Health PlanChildren's Medical Services (CMS)Chinese Community Health PlanChoice Care NetworkCHP GroupChristian Healthcare MinistriesCHRISTUS Health PlanCigna-HealthSpringCitizens Choice Health PlanClark County Self-Funded HealthClements WorldwideCleveland Clinic Employee Health PlanClover HealthCofinityColorado AccessColorado ChoiceColumbia United ProvidersCommon Ground Healthcare CooperativeCommonwealth CareCommonwealth Care AllianceCommunity Behavioral HealthCommunity Care Alliance of IllinoisCommunity Care Behavioral Health OrganizationCommunity Care of North CarolinaCommunity Eye CareCommunity First Health PlansCommunity Health AllianceCommunity Health ChoiceCommunity Health GroupCommunity Health OptionsCommunity Health PartnersCommunity Health Plan of WashingtonCommunityCare of OklahomaCompanion LifeCompBenefitsComprehensive Health Insurance Plan (CHIP) of IllinoisComprehensive Medical and Dental Program (CMDP)ComPsychConnect CareConnectiCareConsolidated Health PlansConsumer Health NetworkConsumers' Choice Health PlanConsumer's Mutual Insurance of MichiganContra Costa Health PlanCook Children's Health PlanCoordinated Care HealthCorvelCountyCare (Cook County)Coventry Health CareCox HealthPlansCrystal Run HealthcareCulinary Health FundDAKOTACAREDavis VisionDC MedicaidDean Health PlanDenver Health Medical PlanDepartment of Medical Assistance ServicesDeseret MutualDevon Health ServicesDMC CareDOCS (Doctors of the Oregon South Coast)Driscoll Health PlanEasy Choice Health Plan (California)Easy Choice Health Plan of New YorkEl Paso First Health PlansElderplanEmblemHealthEmblemHealth (formerly known as GHI)EmblemHealth (formerly known as HIP)EMI HealthEmpire BlueCross BlueShield HealthPlusEmpire PlanEncore Health NetworkEpic Hearing Health CareErickson AdvantageESSENCE HealthcareEvergreen Health CooperativeEvolutions Healthcare SystemsExcellus Blue Cross Blue ShieldEyeMedEyetopia Vision CareFallon Community Health Plan (FCHP)Family Health NetworkFamilyCare Health PlansFidelis Care (NY)First Choice HealthFirst Choice Health Plan of MississippiFirst Health (Coventry Health Care)FirstCare Health PlansFirstCarolinaCareFlorida Blue: Blue Cross Blue Shield of FloridaFlorida Health Care PlansFlorida Health PartnersFlorida Hospital Healthcare System (FHHS)Florida KidCareFlorida Memorial Health NetworkFort Bend County Indigent Health CareFortified Provider NetworkFreedom HealthGalaxy HealthGateway HealthGEHAGeisinger Health PlanGEMCare Health PlanGeneral Vision Services (GVS)GeoBlueGilsbar 360 AllianceGlobal HealthGold Coast Health PlanGolden State Medicare Health PlanGroup Health CooperativeGroup Health Cooperative of Eau ClaireGroup Health Cooperative of South Central WisconsinGuardianGundersen Health PlanGWH-Cigna (formerly Great West Healthcare)HAP (Health Alliance Plan)HAP Midwest Health PlanHarbor Health PlanHarken HealthHarmony Health PlanHarvard Pilgrim Health CareHawaii Medical Assurance Association (HMAA)Hawaii Medical Service Association (HMSA)Health AllianceHealth Care District of Palm Beach CountyHealth ChoiceHealth Choice ArizonaHealth Choice UtahHealth NetHealth New EnglandHealth Partners PlansHealth Plan of NevadaHealth Plan of San JoaquinHealth Plan of San MateoHealth PlusHealth Republic of New JerseyHealth Republic of OregonHealth SunHealthChoice OklahomaHealthlinkHealthNowHealthPartnersHealthPlus of MichiganHealthScope BenefitsHealthSmartHealthSpanHealthyCTHear In AmericaHeritage Vision PlansHFNHFS Medical BenefitsHighMark Blue Cross Blue ShieldHighmark Blue Cross Blue Shield of DelawareHighMark Blue ShieldHighmark BlueCross BlueShield of West VirginiaHillsborough Health Care PlanHome State Health PlanHometown HealthHorizon Blue Cross Blue Shield of New JerseyHorizon Blue Cross Blue Shield of New Jersey For Barbanas HealthHorizon Blue Cross Blue Shield of New Jersey For NovartisHorizon NJ HealthHudson Health PlanHumanaHUSKY HealthIHC Health SolutionsIllinicare HealthImagine HealthIMO (Independent Medical Systems)Independence Blue CrossIndependence Care SystemIndependent HealthIndiana MedicaidIndiana University HealthIngham Health PlanInHealthInland Empire Health PlanInnovation HealthIntegraInter Valley Health PlanINTotal HealthIowa MediPASSItasca Medical CareJohns Hopkins Employer Health ProgramsKaiser PermanenteKansas HealthWaveKelseyCare AdvantageKentucky Health CooperativeKeystone FirstKPS Health PlansL.A. Care Health PlanLand of Lincoln HealthLandmark HealthplanLegacy HealthLiberty Health AdvantageLiberty MutualLifeSynchLifeWiseLighthouse GuildLincoln Financial GroupLouisiana Healthcare ConnectionsLutheran PreferredMagellan HealthMagnaCareMagnolia Health PlanMail Handlers Benefit PlanMaineCareManaged Health Network (MHN)Managed Health Services (Indiana)Managed Health Services (Wisconsin)Managed HealthCare NorthwestMarch Vision CareMaricopa Health PlanMartin's Point HealthCareMaryland Medical Assistance (Medicaid)Maryland Physicians CareMassHealthMayo Medical PlanMcLaren Health PlanMCM MaxcareMDwiseMedicaMedica HealthCare Plans (Florida)MedicaidMedi-CalMedical Eye Services (MES Vision)Medical MutualMedicareMediGoldMediPassMedStar Family ChoiceMedStar Medicare ChoiceMedStar SelectMemorial HermannMercy CareMeridian Health PlanMetLifeMetroHealthMetroPlus Health PlanMetropolitan Health PlanMHNet Behavioral HealthMinuteman HealthMissouri CareMO HealthNetModa HealthMolina HealthcareMontana Health CooperativeMountain Health Co-OpMultiplan PHCSMVP Health CareNational Vision AdministratorsNationwideNavajo NationNeighborhood Health Plan (Massachusetts)Neighborhood Health Plan of Rhode IslandNetwork Health PlanNevada Health CO-OPNevada PreferredNew Hampshire Healthy FamiliesNew Mexico Health ConnectionsNew York Hotel Trades CouncilNorth Carolina Health Choice (NCHC) for ChildrenNorth Shore LIJ CareConnectNovaNetNovaSys HealthNY State No-FaultOhio Health ChoiceOHMS (Oregon Health Management Services)OneNet PPOOptiCare Managed VisionOpticare of UtahOptimaHealthOptimum HealthCareOregon's Health Co-OpOscar Health Insurance Co.OSU Health PlanOxford (UnitedHealthcare)Pacific Health AlliancePacificSource Health PlansPalmetto GBAPan-American Life Insurance GroupParamount HealthcareParkland Community Health PlanParkview Total HealthPartners Health PlanPartnership HealthPlan of CaliforniaPassport Health Plan (Kentucky)Passport To Health (Montana Medicaid)Patient 1st (Alabama Medicaid)PBA (Patrolmen's Benefit Association)Peach State Health PlanPeachCare for KidsPennCarePeoples HealthPhoenix Health PlanPhysician Assured Access SystemPhysicians Health PlanPhysicians Health Plan of Northern Indiana, Inc.Physicians Plus Insurance CorporationPhysiciansCarePiedmont Community Health PlanPiedmont WellStar Health PlansPOMCOPositive Health CarePreferential Care NetworkPreferred Care PartnersPreferred Health SystemsPreferred Medical PlanPreferred Network Access (PNA)PreferredOnePremera Blue CrossPremier Health PlanPresbyterian Health Plan/Presbyterian Insurance CompanyPrestige Health ChoicePrimary Care Case Management (North Dakota Medicaid)Prime Health Services, IncPrimeWest HealthPrincipal Financial GroupPriority HealthPriority PartnersProminence Health PlanProvidence Health PlansProviDRs Care (WPPA)Public Aid (Illinois Medicaid)Public Employees Health Program (PEHP)QualCareQualChoice ArkansasQuality Health Plans of New YorkRegence Blue Cross Blue ShieldRiverLink HealthRiverside HealthRocky Mountain Health PlansSagamore Health NetworkSamaritan Health Plan OperationsSan Francisco Health PlanSanford Health PlanSanta Clara Family Health PlanSCAN Health PlanScott & White Health PlanSecurity Health Plan of Wisconsin, Inc.Select CareSelect Health NetworkSelectHealthSendero Health PlansSenior Whole HealthSeton Health PlanSharp Health PlanSierra Health and LifeSightCareSIHO Insurance ServicesSIMNSA Health PlanSimply HealthcareSolsticeSoonerCare (Oklahoma Medicaid)Soundpath HealthSouth Country Health AllianceSouth Florida Community Care NetworkSpecteraSSM Health CareStandard Life and Accident Insurance CompanyStratoseSummaCareSunflower Health PlanSunshine HealthSuperior HealthPlanSuperior VisionSutterSelectTeachers Health TrustTexanPlusTexas Children's Health PlanTexas Kids FirstTexas Women's Health ProgramThe HartfordThe Health Plan of the Upper Ohio Valley, Inc.The HSC Health Care SystemTotal Health CareTouchstoneTravelersTricareTrillium Community Health PlanTrilogy Health InsuranceTriple-S Salud: Blue Cross Blue Shield of Puerto RicoTrusted Health PlanTuality Health AllianceTufts Health Freedom PlanTufts Health PlanTufts Health Plan-Network HealthUCareUHA Health InsuranceUniCareUniform Medical PlanUnion Health Services, IncUnion PlansUnited Behavioral HealthUnitedHealthcareUnitedHealthcare Community PlanUnitedHealthcare OxfordUnitedHealthOneUnity Health InsuranceUnivera HealthcareUniversal AmericanUniversity Hospitals (Health Design Plus)University of Arizona Health PlansUniversity of Chicago Health PlanUniversity of Utah Health PlansUniversity Physician Network (UPN)UPMC Health PlanUS Family Health PlanUS Health GroupUSA Managed Care OrganizationUSAble Mutual Insurance CompanyValley Health PlanVantage Health Plan, Inc.Ventura County Health Care PlanVillageCareMaxVirginia Coordinated Care (VCC)Virginia Health NetworkVirginia Premier Health PlanVision Benefits of AmericaVision Care DirectVision Plan of AmericaViva Health PlanVNS Choice Health PlansVolusia Health NetworkVSPVytraWEA TrustWellcareWellmark Blue Cross Blue ShieldWestern Health AdvantageWorkers' CompensationWPS Health PlanYourCare Health PlanZenithSelf-PayOther Mensaje * INFORMACIÓN DEL MÉDICO QUE REFIERE Nombre de pila * Apellido * Dirección Teléfono del Médico Fax del Médico
