Request an IN-OFFICE or TELEMEDICINE Appointment Online Only your email and insurance provider information is required prior to submission. Contact us at 919-859-4744 for any questions. Patient's Name First Last Your Name (if different) First Last Patient's Date of Birth Month Day Year Preferred Method of Contact Phone Email Check All Contact Methods That You Would LikePhone NumberEmail(Required) You will receive an email confirmation of your appointment request.Primary Care Provider Please include either your Primary Care Provider's name or their practice name and locationYour Insurance Provider(Required) AARP Aetna Alignment Healthcare Bankers Life Blue Cross/Blue Shield Blue Cross/Blue Shield (State) Blue Cross/Blue Shield (Federal) Blue Medicare Cigna GEHA (Gov't Employees Health Association) Humana Medcost Medicaid Medicare Medicare Rail Road Mutual of Omaha Tricare Tricare for Life UMR United Healthcare I Pay For My Own Healthcare ("Self-Pay") We request your insurance provider so that we may provide more accurate cost information prior to your appointmentAppointment Type Standard In-Office Appointment Telemedicine Appointment ENT Express Care Appointment (Friday am in Clayton / Friday pm in Cary) Please note that our ENT Express Care Clinic accepts same-day appointments Friday 9AM - 12PM in the Clayton Office and Friday 2 PM - 5 PM in the Cary Office with Meghan DeMatta, PA-CAppointment Location Cary Location (601 Keisler Drive, Cary, NC) Clayton Location (in the Summit Medical Center at 11618 US 70 Business Hwy W, Clayton, NC) Telemedicine Appointment Check All Appointment Locations That Are Convenient For You.Preferred Provider Dr. Charles Mann Dr. Jared Spector Meghan DeMatta, PA-C Any Provider, including the PA if sooner ENT Express Care Clinic (Friday AM in Clayton / Friday PM in Cary) Dr. Mann or Dr. Spector only Audiology Allergy Radiology (CT Scans) Check More Than One Provider If DesiredPreferred Appointment Date MM slash DD slash YYYY A Calendar Will Pop Up When SelectedMorning or Afternoon Appointment Preferred? Morning Afternoon Either Morning or Afternoon Is Fine Note That We Are Generally Open Weekdays from 9am - 12pm and 2pm - 5pmReason For My VisitPlease Include a Brief Description of the Problem You Would Like Addressed During Your VisitSend a PictureAccepted file types: jpg, png, pdf, tiff, jpeg, bmp, mp4, wmv, Max. file size: 20 MB.If Helpful, Please Include a Pictures or Video of the Problem AreaMy MedicationsPlease list your medications with dosageOther Medical IssuesPlease list any significant pre-existing medical conditionsPast Surgical ProceduresPlease list any surgical procedures you have undergone in the pastOther Bodily SymptomsPlease list any other recent symptoms you have had, even if you think they are not related to the reason for your visit with us. For example, if you are visiting us for a throat problem, but your joints always hurt, please list that here.Family HistoryPlease list any significant medical conditions that run in your familyAdditional InformationAccepted file types: pdf, txt, jpg, jpeg, png, bmp, doc, docx, Max. file size: 20 MB.Please Upload Any Further Information, Such as Laboratory Studies or Imaging Reports That You Think May Be HelpfulCAPTCHAEmailThis field is for validation purposes and should be left unchanged. Mann ENT Insurance Information We Currently Accept: AARP Alignment Healthcare Aetna Bankers Life Mutual of Omaha BCBS State BCBS Federal BCBS Cigna Tricare Tricare for Life Medicare Medicare Rail Road Medicaid Blue Medicare Medicare Advantage plans GEHA Humana Medcost UMR United Healthcare We Can Help You File a Claim After Being Treated at Mann ENT for “Out of Network” Benefits with ANY INSURANCE PROVIDER, including: Aetna HMO Prime Aetna HMO IPA Cigna Connect Cigna Surefit BCBS Anthem HealthKeepers Blue Value Blue Local Coventry one (with Duke POS as plan type) GHI Duke Select VA Health Choice
