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Indiana Lakes Accountable Care Organization (ILACO)
Indiana Lakes Network

Indiana Lakes Network

Specialty Doctor Name City

Choosing the best care provider for you and your family is easy when you are a part of Goshen Health.

Are you a new or existing patient?

New Existing

*Note: Some offices may require a referral to schedule an appointment.

First Name

Last Name

Address

Address 2

City

State

Zip Code

Email

Phone

Date of Birth (MM/DD/YYYY)

Is this a minor child?

Name of responsible party

Relationship to minor child

Date of birth for responsible party (MM/DD/YYYY)

Preferred language, if other than English

Preferred other language

Insurance Coverage? NoYes

Insurance Carrier Name

Best time of day for Goshen Health to call back Early morning (8-10 am)Mid-morning (10 am - noon)Early afternoon (noon - 2 pm)Late afternoon (2-4 pm)

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