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RightCare Outreach Team Member

Request to be Contacted by a RightCare Outreach Team Member

By filling out this form you are consenting to being contacted by RightCare part of Baylor Scott and White Health Plans via phone.

1. Name (Nombre) *This question is required.

2. Member ID Number (Número de identificación de miembro) *This question is required.

3. Phone Number (Número de teléfono) *This question is required.

4. County where you live (Condado donde vives) *This question is required.

5. Requesting help with: (Solicitando ayuda con:) *This question is required.

Medicaid Benefits (Beneficios de Medicaid)
PlanPerks (Beneficios adicionales del plan)
Reenrollment (Reinscripción)
Change of primary care physician (Cambio de médico de atención primaria)
Other Please enter an 'other' value for this selection.

6. Would you like help getting connected with local community resources for housing, food etc.? (¿Le gustaría recibir ayuda para conectarse con los recursos de la comunidad local para vivienda, comida, etc.?) *This question is required.

7. What are you requesting resources for? select all that apply. (¿Para qué necesitas recursos? seleccione todas las que correspondan) *This question is required.

Housing (Alojamiento)
Food (Comida)
Finance (Finanzas)
Accessing health care (Cuidado de la salud)
Accessing Behavioral Health Services (Servicios de salud conductal)
Education (Educación)
Other Please enter an 'other' value for this selection.