Insurance Checker

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
Inactive State
Out of Network Type
Pacific Pilot
Insurance Checker

Check if we're in network in just a few questions
What State Do You Live In?
Home State*

Street Address

Street Address Line 2

CityState

Zip Code

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
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.

Personal Info

Safe, confidential, and affordable treatment for opioid use disorder via our telehealth services.
Full Legal Name*

Legal First Name (MUST MATCH ID)Legal Last Name (MUST MATCH ID)
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Birthday *

MonthDayYear
Date of Birth

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

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:

Insurance Checker

What State Do You Live In?

Insurance

Personal Info

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

Authorization to Share Information

Terms and Conditions