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First Name*

Last Name*

Email*

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Select Preferred Location*

State of Residence?*

If not in the US select "International"

Are you or the client(s) covered by Medicaid, CHP+ or a Medicare disability plan?

* We do accept some Medicaid plans, but will need to verify benefits.

Medicaid ID Number*

Date Of Birth*

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* You will also receive a confirmation text and email upon submitting this form.

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*By checking YES, you agree to receive text communication from our office and billing teams.

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Cornerstone accepts CCHA Medicaid but does not bill other insurances. We do provide superbills for potential reimbursement.

Frequently Asked Questions (FAQ)

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