Book Open Enrollment Appointment

"*" indicates required fields

Name*

First Last

What is your Language Preference?*

English

Español

Date of Birth*

Mobile Phone Number*

Please provide a mobile phone number. Make sure you have access to the provided phone number as a confirmation text will be sent to this number.

SMS Text Message*

I agree to receive SMS Text Messages

I authorize Nevada Medication Assistance Program (NMAP) and Access to Healthcare Network (AHN) to contact me by SMS text message for program related information. Message & data rates may apply.

Are you a Ryan White Provider Scheduling an appointment on behalf of your client?*

No

Yes

Please fill out your name and email address.

Ryan White Case Worker's Name*

First Last

Case Worker's Email*

Enter Email Confirm Email

By providing your email address, you will receive email notifications regarding this appointment from Nevada Department of Health and Human Services.

Appointment Confirmation*

Please select how you would like to receive appointment reminders.

SMS Text Message

Email

Email*

Enter Email Confirm Email

Please make sure you have access to the provided email address as a confirmation email will be sent to this email address.

Email Agreement*

I agree to receive Email Messages

By providing your email address, you will receive notifications regarding your appointment from Nevada Department of Human Services.

Choose Insurance / Specialist / Date & Time

Choose Insurance*

Please tell us your current health insurance situation.

MEDICARE AND MEDICAID GUIDE

Uninsured – English

This field is hidden when viewing the form

02 - Booking Flow

This field is hidden when viewing the form

02 - Service

Choose Your Insurance Specialist *

Note: Each specialist has different availability dates / times. If a preferred time / date is not available, try choosing a different specialist.

Choose Appointment Date / Time

Uninsured – Español

This field is hidden when viewing the form

03 - Booking Flow

This field is hidden when viewing the form

03 - Service

Choose Your Insurance Specialist

Note: Each specialist has different availability dates / times. If a preferred time / date is not available, try choosing a different specialist.

Choose Appointment Date / Time

Insured – English

This field is hidden when viewing the form

04 - Booking Flow

This field is hidden when viewing the form

04 - Service

Choose Your Insurance Specialist

Note: Each specialist has different availability dates / times. If a preferred time / date is not available, try choosing a different specialist.

Choose Appointment Date / Time

Insured – Español

This field is hidden when viewing the form

05 - Booking Flow

This field is hidden when viewing the form

05 - Service

Choose Your Insurance Specialist

Note: Each specialist has different availability dates / times. If a preferred time / date is not available, try choosing a different specialist.

Choose Appointment Date / Time

Medicare Enroll/Re-enroll – English

This field is hidden when viewing the form

06 - Booking Flow

This field is hidden when viewing the form

06 - Service

Choose Your Insurance Specialist

Note: Each specialist has different availability dates / times. If a preferred time / date is not available, try choosing a different specialist.

Choose Appointment Date / Time

Medicare Enroll/Re-enroll – Español

This field is hidden when viewing the form

07 - Booking Flow

This field is hidden when viewing the form

07 - Service

Choose Your Insurance Specialist

Note: Each specialist has different availability dates / times. If a preferred time / date is not available, try choosing a different specialist.

Choose Appointment Date / Time

Medicaid Enroll/Re-enroll – English

This field is hidden when viewing the form

08 - Booking Flow

This field is hidden when viewing the form

08 - Service

Choose Your Insurance Specialist

Note: Each specialist has different availability dates / times. If a preferred time / date is not available, try choosing a different specialist.

Choose Appointment Date / Time

Medicaid Enroll/Re-enroll – Español

This field is hidden when viewing the form

09 - Booking Flow

This field is hidden when viewing the form

09 - Service

Choose Your Insurance Specialist

Note: Each specialist has different availability dates / times. If a preferred time / date is not available, try choosing a different specialist.

Choose Appointment Date / Time