Connect with a Careway Advocate

We're excited to help you access the care you deserve with personalized advocacy services covered by Medicare.

Fill out this form, and we'll contact you to connect you with an advocate.

If you prefer, give us a call at 413-GET-CARE (413-438-2273)

Who is filling out this form?

I'm filling this out for myself I'm filling this out for someone else

Your Information Patient Information

Your Name Patient's Name *

Your Email Patient's Email *

Your Phone Patient's Phone *

10-digit phone number

State you live in State they live in *

Note: We currently do not operate outside of CA, FL, MI, OH, WI. More states are coming soon, so you can still join the waitlist.

Why are you interested in Careway? (Optional) Why are they interested in Careway? (Optional)

Your Information

Please provide at least one way for us to contact you (email or phone number)

Your Name *

Your Relationship to Patient *

Your Email

Your Phone

10-digit phone number

Communication Preferences (Optional)

Help us reach you at the right time

Who should we contact? *

Patient directly Supporting individual

Preferred contact method(s)

Phone Email Text Message

Best time to contact

Contact preferences or notes

Medicare Information (Optional)

Help us verify eligibility faster - if you have it handy!

Note: Patients with Original Medicare typically qualify for our services. Medicare Advantage support is coming soon, and patients can still join the waitlist.

Most of our patients pay $0 out of pocket. We'll confirm eligibility during our initial consultation.

Your Date of Birth Patient's Date of Birth

Your Medicare ID Patient's Medicare ID

Format: XXXX-XXX-XXXX

Policies

Please review and agree to the following policies:

I agree to all policies below

I agree to the Consent to Treatment and Telehealth Policy * I agree to the Agreement of Financial Responsibility * I agree to the Electronic Communication User Agreement *

* Required fields. Please review each policy by clicking the links above.

Call 413-438-2273 Email hello@careway.health