Appointment Request

Name*
Email*
Phone
Do you have Johns Hopkins EHP insurance?We are considered out-of-network providers by most health insurance plans (for details on using out-of-network benefits go to https://newconnectionscounselingcenter.com/rates-and-insurance); however, the only insurance plan we are IN-network with is Johns Hopkins EHP insurance.
Date of Birth
Comment or Message
By submitting this form via this web portal, you acknowledge and accept that risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Brighter Vision harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means. *Yes, I want to submit this form

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