Appointment Assistance Request

1. NJ Form Panel

• NJ Form Panel

Nj-carecoordination@elevancehealth.com

Your contact information

First Name

Last Name

Member ID#

You’ll find this number on your member identification card.

Phone Number

Email Address

Your request details

What type of provider or specialist do you need?

If you want an appointment with a specific provider, please enter their first and last name.

Do you need help arranging transportation for healthcare visits?

Yes

No

Have you already contacted us to ask for help making an appointment?

Yes

No

Please give the date you contacted Member Services.

Date of contact is required.

Date of contact should not be more than current date.

Submit

If you want to make a formal complaint (also called “filing a grievance”), you can do that by going to Grievances and Appeals.