Patient Lead Capture

BH Jotform Type (engineering use only)*
This determines what automation is triggered. (
Referral Source
Referral Medium
Referral Campaign
Referral Content
Referral Term
Referral Referrer
Source Mix Panel
Business Hours
Out of Network Type
Inactive State
Let's Get Started

We need some basic info to start.
Full Legal Name*

Legal First Name (MUST MATCH ID)Legal Last Name (MUST MATCH ID)
Email*
example@example.com

What State Do You Live In?

Our science-backed approach boasts 95% of patients reporting no withdrawal symptoms at 7 days.
Home State*

Street Address

Street Address Line 2

CityState

Zip Code

Have you been seen by a Bicycle Health provider in the past?

If you have previously been a patient with us, you will need to speak with an enrollment coordinator over the phone to complete enrollment
Are a new patient or are you re-enrolling?*

I am a new patientI have been seen by a Bicycle health Provider in the past
Are you currently experiencing withdrawal symptoms OR do you anticipate withdrawal within the next 24 hours?*

YesNo

Personal Info

Safe, confidential, and affordable treatment for opioid use disorder via our telehealth services.
Phone Number*
Please enter a valid phone number.
Birthday *

MonthDayYear
Date of Birth

Insurance

We accept most health insurance plans, although the extent of your coverage will depend on your specific plan.
Do you currently have insurance?*

YesNo
What type of insurance do you have?*

MedicareMedicaidCommercial or Other (Through employer, Marketplace, or Spouse/Parent)
Calculated: State|Type
Calculated: State + Type (eg. ColoradoMedicare)
Calculated: State|Company (+Medicaid)
Calculated: This is state + commercial company + medicaid plan + all of the medicaid dropdowns
Calculated: State|Company|Type
Calculated: This is State + Company + Type
Which insurance company is your insurance through? (Commercial)*
Which insurance company is your Medicare plan through? *
Which insurance company is your Arizona Medicaid plan through? *
Which insurance company is your Maryland Medicaid plan through? *
Which insurance company is your Michigan Medicaid plan through? *
Which insurance company is your Nebraska Medicaid plan through? *
Which insurance company is your New Mexico Medicaid plan through? *
Which insurance company is your Oregon Medicaid plan through? *
Which insurance company is your Texas Medicaid plan through? *
Which insurance company is your Virginia Medicaid plan through? *
Which insurance company is your Washington Medicaid plan through? *
Which insurance company is your Medi-Cal Medicaid plan through? *
Calculated: chosen insurance
Calculated: chosen insurance that will prefill the enrollment form
Great! We offer an affordable self-pay option of only $249/month!

This includes:
✅️ All of your doctor visits (via video calls)
✅️ Unlimited instant messaging & care navigation
✅️ Online groups
Great news! We are in network with Cigna!

During enrollment, we will verify the specifics of your plan and coverage benefits.
Great news! We are in network with Anthem

During enrollment, we will verify the specifics of your plan and coverage benefits.
Great news! We are in network with BlueCross BlueShield!

During enrollment, we will verify the specifics of your plan and coverage benefits.
Great news! We are in network with Aetna!

During enrollment, we will verify the specifics of your plan and coverage benefits.
Great news! We are in network with Mercy Care!

During enrollment, we will verify the specifics of your plan and coverage benefits.
Great news! We are in network with United Healthcare!

During enrollment, we will verify the specifics of your plan and coverage benefits.
Great news! We are in network with Molina!

During enrollment, we will verify the specifics of your plan and coverage benefits.
Great news! We are in network with McLaren!

During enrollment, we will verify the specifics of your plan and coverage benefits.
Great news! We are in network with Medicaid in your state!

During enrollment, we will verify the specifics of your plan and coverage benefits.

Authorization to Share Information

Our mission is to help people find high-quality, affordable treatment for opioid use disorder. You can help us.

Terms and Conditions

In order to enroll with Bicycle Health, you must agree to the following terms:
Should be Empty:

Let's Get Started

What State Do You Live In?

Have you been seen by a Bicycle Health provider in the past?

Personal Info

Insurance

Authorization to Share Information

Terms and Conditions