BayCare Registration Form

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Gender * -Select- Female Male Other Prefer not to answer

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State * -select- AA AE AK AL AP AR AS AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VI VT WA WI WV WY

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How did you hear about us? * -select- Baycare Website Google Insurance News Story None Primary Care Physician Referring Physician Word of Mouth

Locations with Provider * -select location- Mease Dunedin Hospital - Dunedin/Clearwater South Florida Baptist Hospital - Plant City St. Anthony's Hospital - St. Petersburg St. Joseph's Hospital - Tampa St. Joseph's Hospital South - Riverview Winter Haven Hospital - Winter Haven

Provider * -select provider-

Insurance Provider (select "N/A" if not insured) * -select- N/A Blue Cross Blue Shield SURGERY PLUS/EMPLOYER DIRECT HEALTHCARE - AARP AARP Medicare Advantage Focus UHC AARP Medicare Complete Choice PPO AARP medicare UHC complete AARP UHC complete AARP UHC Medicare Administrative Concepts Administrative Concepts Inc Advent Health Aetna aetna hmo Aetna Better Health Aetna Choice POS II Aetna Dual Aetna Healthscope Aetna Medicare Supplement Aetna Meritain Aetna Open Access aetna QHP Aetna Select Aetna Supplement Plan B Aetna Supplemet plan G Aetna/Quantum All Savers Insurance allegiance Allegiance Allied allied PHCS ALLIGIANT Allways Health Partners Ambetter Ambetter Core Bronze ambetter silver Ameriben Ameriben Anthem BCBS Amerigroup Amerigroup Medicaid HMO Amfirst Angle Health Anthem Anthem BC Anthem BCBS Anthem BCBS of CT PPO Anthem BCBS of OH Anthem Empire anthem medicare atena AVMed AvMed - AvMed-HMO, POS, PPO BAS Health Baycare Financial Aid Baycare Health Saving Account Baycare Medicare BayCare Plus Medicare Advantage Baycare Premium Baycare Share BC Blue Options BC Health Options bc ppc BCBS PCSB BCBS AL BCBS Arkansas bcbs blue options BCBS BLUE PPO BCBS Federal BCBS FL Walmart bcbs health options bcbs hmo BCBS Independence Geo Blue BCBS Independence Network Blue PPO BCBS Interstate BCBS MA Medicare Supp BCBS MI BCBS of AL BCBS of AR BCBS of AZ BCBS of CA BCBS of FL PPO BCBS of IN BCBS of Kansas City BCBS of KY bcbs of Massachusetts BCBS of MI PPO BCBS of MS BCBS of Nebraska BCBS of North Dakota BCBS of Oregon BCBS of Puerto Rico BCBS of RI BCBS of VT BCBS of Western New York BCBS Polk County Schools Blue Option BCBS SC/Quantum Benefit Administration Systems better health medicaid BIND Bind Benefits (uhc) blue cross BLUE CROSS ANTHEM Blue Cross Blue Shield of Texas Blue Cross Blue Shield of Vermont Blue Cross/Blue Shield - BC/BS-POS, PPC, Traditional, EPO, PPO (Blue Choice) Blue Florida Traditional Blue Medicare Choice blue options BLUE OPTIONS Blue Shield of California Blue Shield of Northeastern New York Boon-Chapman Bright Health Bronia Machado Luque Cardinal Choice Multiplan Care Valent Carefirst Blue Choice Carelink Champa VA Cigna Cigna - BayCare Hybrid Cigna Baycare Share Cigna Disney Cigna for Baycare Cigna HMO Cigna Medicare Cigna Medicare Supplement Cigna Preferred savings HMO Cigna-PHCS Clear Health Alliance Medicaid Commonwealth Care Alliance Community Medical Group Companion Life Coventry - PPO Credence BCBS Curative First Health Devoted Health Diversified Administration Corp Doctor's Gessler Clinic Dual l needs plan EBMC First Health Network EBMS Edison Health Solutions Emblem Emblem UMR Empath Suncoast Pace Enterprise Group Evercare United Evolutions Excel Federal Blue Cross Blue Shield Federal Life First Health Network fl blue hmo silver Fl Blue Medicare FL Blue Select FL Blue State of Florida Employee Florida Blue Florida Blue (medicare plan G) Florida Blue Blue Care florida blue Blue Options Florida Blue Blue Select Florida Blue Cross florida blue excellus FLORIDA BLUE EXCELLUS Florida Blue HMO Florida Blue Medicare Florida Blue Medicare HMO Florida Blue Medicare Supplement florida blue my blue Florida Blue PPO Florida Community Care Medicaid Florida Department of Health Florida Health Administrators Florida Hospital FLORIDA MEDICAID Focus Silver HMO Freedom Life Insurance GBS Healthy Advantage General Insurance Co Golden Rule through United Healthcare GPA Group and Pension Admin Gulf Coast Insurance Health Alliance of Michigan Health First Health New England health options Health Options/Blue Care Healthy Horizons of Florida Highmark BCBS Hillsboro County Healthcare HIllsborough County Insurance Horizon BCBS Humana Humana HealhCare Plans - Humana-HMO, POS, PPO, Staff HMO Humana HealthCare Plans - Humana-Choice Care Humana Medical Plan Humana Plan F Humana POS Imagine 360 INsurance Healthscope Benefits Johns Hopkins Health Network Lantern Lifeshield Loomis Lucent Health/Cigna Lutheran Maestro Health Magellen Medicaid Marpai Health MD BCBS Fed Medicaid Medical Mutual of OH Medicare Medicare BCBS PPO Medicare Complete with AARP Medicare of Florida First Coast Medicare Part A Medicare Part B Medicare Plan G Medipass Meritain Health Midwest Operating Engineers Retirement Plan MSA Mutual Omaha my blue My Blue My Blue HMO N/A NALC Need insurance information NGL Nova Healthcare Administrators NPI Optimed Oscar Oscar Health Other Pan American paramount under cornerstone Peachstate PHCS PHCS (Medishare) PHCS Total Plan PHCS/Lucent Health Philadelphia American Polk County Healthcare Polk Health polk health plan Polk Healthcare Plan Polk School Board Preferred One Priority Health PPO Private HCS Generic Qual Choice Quantum BCBS Quantum Health Quantum Hst Open Access Railroad Medicare Regence SBMA-Affinity Living Group LLC SC BCBS Fed Seattle VA Seguro Self Pay SELF PAY selman and company Sidecar Health Simply simply complete Simply Healthcare Simply Healthcare Medicaid Policy Simply HMO simply level hmo Simply Medicaid Simply Medicare simply more hmo SISCO Staywell Sunshine Sunshine Medicaid Surest SurgeryPlus The Empire Plan New York State The Health Plan TPH The Health Plan TransAmerica TransChoice tricare Tricare Tricare Humana Tricare Select Tricare West Trustmark Benefits Tufts UHC AARP Supplemental UHC Dual Eligible UHC Indemnity Plan UHC MCR Dual Complete UHC MCR Dual Complete Partial UHC Medicaid UHC Medicare UHC Medicare Supplemental UHC Select Plus UHC/Harvard Pilgrim UHC/Medicare UHP Administrators Ultimate Medicare UMR UMR Quantum UMR UHC UMR/Integrated United American United Complete Focus HMO United Health Care Choice UNited Health Care Prime United Health Dual Complete United Health Plan PHCS United Healthcare United Healthcare Dual Complete United HealthCare MCR Dual Complete United Healthcare of FL - Medicare Complete/Evercare/Secure Horizons United HealthCare of Florida - United-HMO, PPO United MCR/Wellmed United Medicare/Wellmed united neighborhood healthplan Univera Health Care UPMC US Health Group USAA Life Insurance VA VA Community Care watson clinic healthscope Well Protector Wellcare welldyne Wellmed UHC dual complete WPS Health/ THE Epic Life Insurance zTricare

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Previous Bariatric Surgery? -select- Yes No