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  At Galaxy Health Network, we aim to have the medical care providers you need where you need them - when you need them.  From time-to-time, it comes to our attention that a specific type of medical care provider is not conveniently available to our members. 
   
  If you've searched for a provider and can't find one close to you, please complete the information below and submit it to us.  We will do our level-best to find the provider you need within 24 to 48 hours of your request. 
   
  Section 1 - Member Information
   
 
Member ID:*  
First Name:*  
Last Name:*  
Email Address:*  
Phone:*  
Street Address:*  
City:*  
State:*  
Zip:*  
Medical Condition:
   
 
Section 2 - Provider Requirements
Language Spoken:*
Provider Specialty or Service Needed:*  
Maximum Distance* from Home Address:  
Other Requirements: (please specify)

*Required

 

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