Appointment Request

This request form is for new patients only. If we have seen you before then we have your information already and you can just email us at appointments@rdmaui.com or you can fill out the appointment request for established patients if any of your information changed (eg. address, insurance, phone etc.)

Please continue. We will call you back in the order the requests have been received (usually 1-2 business days).

Coverage Information:
Coverage Information: Out-of-PocketInsurance

Please select your insurance below. If your insurance is not listed, we can still see you but you will be expected to pay out-of-pocket (please select the 'Out-of-Pocket' option above and proceed). Please Note: We do not accept any Medicare Advantage plans or Medicaid plans (Quest) unless they are administered by HMSA.

You selected an insurance plan that requires a referral. Please note that without a referral from your Primary Care Provider (PCP) your insurance will deny coverage and you will end up paying out-of-pocket.
I'm aware that my insurance will likely deny coverage and I ...
...will contact my PCP to get a referral. Please call me once you receive that referral to schedule an appointment....agree to pay out-of-pocket.

Thank you for filling out this form. You can close this tab. We will call you as soon as we have received and processed the referral from your primary care provider.
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Please take images of your insurance cards or upload PDFs. Alternatively, you can also just provide the member number/ID manually in the field below.

Primary Coverage (front and back):
...or type member number/ID:

Secondary Coverage (front and back):
...or type member number/ID:

Your Name

Date of Birth

Address

Phone Number

Your cart

Your Cart