To request an appoinment for FAMILY HEALTH INSURANCE PROGRAM,
please complete the following form we will contact you as quickly as possible.

Appointment Information
I would like my appointment in:
or I live in:

Applicant Information
First Name
Last Name
Insurance Provider
Insurance Expiration
This appointment would be a

A New Application
A Recertification
For A Wage Earner who is

Contact Information
Preferred appointment day of the week?
Preferred Appointment Time
How can we reach you best by phone? ( ) -
Best time to call?

Morning
Afternoon
Evening
OK to leave a message?

Yes
No
Email Address
Additional Comments


Please note that when requesting an appointment, this form does not guarantee an appointment time.

A member of our staff will contact you by phone for
appointment conformation.

If you require immediate or further assistance please contact us directly by calling:

Jefferson County
(315)782.2490

St. Lawrence County
(315)386.8128

Franklin County
518.483.4262

238 Arsenal St.
Watertown, NY 13601
P. (315)782-9450  F. (315)782-2643


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North Country Children's Clinic, Inc. • 238 Arsenal St. •  Watertown, NY 13601
P. (315)782-9450 F. (315)782-2643