Request an Appointment with Valerie Jacobson, MD

First Name:* Middle Initial:

Last Name:*

Street Address:

City, State Zip - AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MI MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY

Primary Phone Number:* Type: - Home Cell Work

Secondary Phone Number: Type: - Home Cell Work

Email Address:*

Preferred Contact Method:* (No preference) Daytime Phone Home Phone Cell/Mobile Phone Email A Valerie Jacobson, MD Scheduling Agent will contact you to confirm your appointment. Please select the method you prefer for us to contact you.

Date of Birth:*

Insurance:* (Insurance not listed) (No insurance) Aetna HMO, POS, QPOS, Open Access, Select Aetna Open Choice PPO Aetna Elect Choice / Health Choices Aetna Managed Choice Aetna National Advantage Program Aetna Signature Administrator AvMed Beech Street PPO Blue Cross Blue Shield HMO (HOJ) Blue Cross Blue Shield Indemnity (PHS) Blue Cross Blue Shield PPO (PPC) Blue Cross Blue Options (Network Blue) Capital Health Plan CIGNA HMO CIGNA PPO CompCare Psych Evolutions Healthcare Systems FCCJ Student Insurance First Health PPO Great West Healthcare Humana EPO Humana HMO Humana PPO, POS & Open Access LifeSynch MDI Healthcare Multiplan Private Healthcare Systems Southcare United Behavioral Health United HMO United Open Access United POS United PPO Aetna Medicare HMO Blue Cross Blue Shield Advantage 65 United AARP Medicare Complete / SecureHorizons/ Evercare/ UnitedHealthcare Dual Complete (Community Plan)/ WellMed HMO & PPO USA Care Medicare PFFS Sunshine State Health Plan United Healthcare Community Plan Beech Street WC Blue Cross WC Coventry WC Focus WC Prime Comp Network WC Tricare Standard ValueOptions for Tricare Members Tricare Prime Value Options for commercial products Florida Self Directed Care Magellan PPO MHNet Blue Cross Blue Shield - BH Employees Medicare SmartHealth (Select offices) HealthEase Healthy Kids *(Select Offices Only) Ped-I-Care (select offices) Medicare - Railroad Blue Cross Medicare PPO (BlueMedicare Regional PPO) Coventry Health Care of Florida HMO Prime Comp Network WC (select offices) Humana Medicare Heritage Summit WC Medicaid FL Aetna - ACA Exchange Plans Blue Cross Blue Shield HMO - ACA Exchange Plans Blue Cross Blue Options (Network Blue) - ACA Exchange Plans Sunshine State Health Plan (select offices) United Community Health Plan (select offices) United Healthy Kids (select offices) Coventry PPO, POS Humana Medicare - Select Offices Only Blue Cross Medicare HMO (Except BlueMedicare Preferred HMO/Alignment Health) First Coast Advantage United Compass - ACA Exchange Plans AvMed Engage HMO AvMed Empower POS Assurant Health - Aetna ASA - ACA Exchange Plans Blue Cross Blue Shield myBlue Choice Care PPO Multiplan WC Aetna Medicare PPO Cigna Behavioral Health Humana Behavioral Health Aetna Whole Health

Preferred Date #1:* at Any Time Early A.M. Late A.M. Early P.M. Late P.M.

Preferred Date #2: at Any Time Early A.M. Late A.M. Early P.M. Late P.M.

Preferred Date #3: at Any Time Early A.M. Late A.M. Early P.M. Late P.M.

Primary reason for visit:*