Thank you for agreeing to help serve some of the 150,000 uninsured patient in Oklahoma City.

We at the Health Alliance for the Uninsured want to make sure that this is a smooth process for you. Some input from you will help.

Date:

Your Name:

Your Specialty:

Who we contact to schedule appointments:

What hospital(s) do you work with:

Phone Number:

Email Address:

How many patients would you “be willing” or “be able” to see in a year? (Select your preference)
1 per month1 per quarter2 per month2 per quarter3 per month3 per quarter

What information would you like prior to the patient seeing you? (We will send the records from the PCP.)

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