Covid-19 Vaccine Appointment Form – Part 1 Home / Covid-19 Vaccine Appointment Form – Part 1 Qualifications: You must have one of the following to qualify to receive the Covid-19 vaccine at this time. - You must be NYS resident - 18 and above Are you a New York Resident?* YesNo Do you qualify based on the list above?* YesNo Are you a healthcare worker?* YesNo Are you a employee of NuHealth?* YesNo You are not currently eligible at time. Please check back at a later date. Patient Information First Name* Middle Initial Last Name* Address* City* State* Select...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip* Email* Phone* Date of Birth* Gender* MaleFemale Health Insurance* No Insurance Aetna Aetna HMO Affinity Affinity Health Plan American Medical & Life AmeriChoice Atlantis Beacon Hill (Mental Health) Beech Street Beech Street: Via NYNM Better Health Advantage Care Plus Care Plus: Via NYNM CenterCare CenterCare: Via NYNM CHN CHN: Via NYNM Cigna Cigna Agreement Cigna Behavorial Health Cigna HMO Cigna HMO/POS/OAP/PPO Community Care Network (CCN) Community Care Network (CCN): Via NYNM Devon Health Services Devon Health Services: Via NYNM EBCBS - pain management Elderplan Empire BC/BS HMO Empire BCBS Empire BCBS PPO/CHP/Indemnity Empire BCBS PPO/EPO Empire BCBS PPO/Indemnity Empire BCBS-All products Evolutions Evolutions: Via NYNM Fidelis First Health First Health: Via NYNM Galaxy Galaxy: Via NYNM GHI HMO GHI PPO GHI PPO/EPO Great West Health Care Partners IPA Health First Health Net Health Net: Via NYNM Health Plus Health Plus/Pediatric Psychiatry Health Plus: Via NYNM Healthcare Partner - HIP Healthcare Partners-Healthnet Healthfirst HealthStar HealthStar: Via NYNM HIP HIP- Hempstead Horizon Healthcare of NY Horizon Healthcare of NY: Via NYNM Humana Liberty Health Advantage Liberty Health Advantage Local 1199 Local 32 B-J via EBCBS PPO Magnacare MDNY Medicaid Medicare Medicare Multiplan Multiplan/PHCS Multiplan: Via NYNM Neighborhood NYNM Oxford Oxford Health Plan PHCS PHCS: Via NYNM POMCO Railroad Medicare SSRIPA Tricare Prime HMO TriCare Standard TRPN - Three Rivers Network United Behavioral Health United Empire United Empire Plan United Healthcare United Healthcare Up + Up Value Options Vytra Wellcare Workers' Compensation Insurance #* Go to Step 2 *Please only click the button 1 time. REMINDER: PLEASE WASH YOUR HANDS AND USE HAND SANITIZER PLEASE DO NOT SHAKE HANDS, TOUCH OR HUG DURING YOUR VISIT WEAR MASK AT ALL TIMES!!!