Houston Methodist. Leading Medicine.
Houston Methodist. Leading Medicine

Email Forms Manager

Thank you for your interest in Center for Performing Arts Medicine.

To protect your privacy, all of our online forms are encrypted and stored in a secure location. Please note that while our forms are secure, any communication via e-mail may not be secure, so please consider that when selecting a way for us to contact you.

If you do not have health insurance and believe you qualify for financial assistance, please call our Financial Counseling office in Patient Access Services at The Methodist Hospital. The phone number is (713) 441-6807 and they will be pleased to answer any of your questions about the program and arrange a meeting with a financial counselor if the situation warrants.

* Indicates required information
Patient's First Name * 
Patient's Middle Initial 
Patient's Last Name * 
Patient's Address1 * 
Patient's Address2 
City * 
State * 
Zip Code * 
Country 
Daytime Phone Number * 
Evening Phone Number 
Patient's E-mail Address * 
Date Of Birth * 
Gender 
Performance Area 
Primary arts employer 
Position 
Insurance Billing Information 
Primary carrier 
Primary carrier effective date 
Primary carrier address 
Primary carrier city 
Primary carrier State, Zip 
Primary carrier subscriber 
Primary carrier policy number 
Primary carrier group name 
Primary carrier group number 
Primary carrier telephone 
Secondary carrier 
Secondary carrier effective date 
Secondary carrier address 
Secondary carrier city 
Secondary carrier state, zip 
Secondary carrier subscriber 
Secondary carrier policy number 
Secondary carrier group name 
Secondary carrier group number 
Secondary carrier telephone 
Tertiary carrier 
Tertiary carrier effective date 
Tertiary carrier address 
Tertiary carrier city 
Tertiary carrier state, zip 
Tertiary carrier subscriber 
Tertiary carrier policy number 
Tertiary carrier group name 
Tertiary carrier group number 
Tertiary carrier telephone 
How Did You Find Out About Us? * 
Additional Information 
By selecting this box and the "Submit" button, I agree to the Disclaimer and Privacy Policy* 
Authentication * 

If the challenge words are too difficult to read, click here to refresh.