New Patient Request

Maryland Medicaid
NEW PATIENT REQUEST FORM

Maryland Medicaid patients are seen by Amy Grammas, CRNP-PMH through the Family Support Therapy Center (FSTC) network. After you complete the basic information below, you will be sent an email to set up your Simple Practice account. This is the HIPAA compliant platform for all communications, scheduling and appointments. Once you have completed the intake paperwork, FSTC will need to call Medicaid for authorization. When approved, you will be alerted that you can begin scheduling appointments (this usually takes 1-2 business days).

* Indicates required field

Legal Name *

First

Last

Email *

Cell Phone Number *

Is it ok to send you text reminders of appointments, cancellations and/or paperwork that is due? *

Yes No

I am at least 18 years old *

Yes

Primary Insurance *

Medicaid Number *

Upload a copy of your Maryland Medicaid Card *

Max file size: 20MB

Upload a copy of your MCO Insurance Card *

Max file size: 20MB

This request is not an emergency or urgent matter - I wish to proceed *

Yes

After you have been approved for services, you will receive an email with a link to the Simple Practice Healthcare Portal to set up your account.

*This information will be sent to a non-HIPAA compliant email. Please note this is not a secure means of communication so your confidentially cannot be ensured.

Submit

Maryland Medicaid ​​NEW PATIENT REQUEST FORM

After you have been approved for services, you will receive an email with a link to the Simple Practice Healthcare Portal to set up your account.

Maryland Medicaid
NEW PATIENT REQUEST FORM