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
Bicycle Health Sign Up

It takes just a few minutes to create your account.
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

Unfortunately, we aren’t serving patients in your state just yet. If you would like to be notified when we are live in your state, click submit below!

Here are some resources you may find helpful are:

Substance Use Treatment Locator: provides information on state-licensed providers who specialize in treating substance use disorder.

Call 1-800-662-HELP (4357) or TTY 1-800-487-4889: provides substance use disorder information and treatment, 24-hours a day in English and Spanish.

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? *
Calculated: chosen insurance
Calculated: chosen insurance that will prefill the enrollment form
We offer an affordable self-pay option of only $199/month!

This includes:
✅️ All of your doctor visits (via video calls)
✅️ Unlimited instant messaging & care navigation
✅️ Online groups

Our Self-Pay plan does not include the cost of any prescribed medications.

If you enroll, our pharmacy team will assist you with finding the most cost-efficient pharmacy in your local area. If need be, we can try to supply you with vouchers that will substantially cut down the costs of the medication.
We cannot accept your insurance at this time. We do offer an affordable self-pay option for $199/month.

This includes:
✅️ All of your doctor visits (via video calls)
✅️ Unlimited instant messaging & care navigation
✅️ Online groups

Our Self-Pay plan does not include the cost of any prescribed medications.Your insurance may cover those costs.

If you enroll, our pharmacy team will assist you with finding the most cost-efficient pharmacy in your local area. If need be, we can try to supply you with vouchers that will substantially cut down the costs of the medication.
Bicycle Health is not a medicaid provider in your state. We do offer a self pay rate of $199 monthly to ensure affordable access to our care.

This includes:
✅️ All of your doctor visits (via video calls)
✅️ Unlimited instant messaging & care navigation
✅️ Online groups

Since you will be seeing a non-medicaid provider, your insurance will not pay for any medications prescribed by your Bicycle Health provider, and you will be responsible for that cost as well. Our team can help provide you with coupons to help reduce the cost as much as possible.
We apologize, but we currently are unable to accept your insurance at this time.

To find assistance in your state, please visit the Substance Abuse and Mental Health Services’ Buprenorphine Practitioner Locator.

Evidence-based treatment that works for opioid addiction.
How would you like to proceed?*

Enroll online (Quickest)Schedule a callCall us now

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:

Bicycle Health Sign Up

What State Do You Live In?

Personal Info

Insurance

Evidence-based treatment that works for opioid addiction.

Authorization to Share Information

Terms and Conditions