Health Plans Application
First Name*
Middle Initial
Last Name*
Address*
City*
State*
California
Texas
New York
Florida
Zip Code*
Phone Number*
Email*
Date of Birth*
Gender *
Male
Female
Is the applicant, spouse/domestic partner/significant other, dependent children, or any other member of their household currently being treated for, or expect to be treated for any of the following over the next 12 months?
Organ failure, leading to bone marrow or organ transplant *
Yes
No
Any genetic condition that requires cell or gene therapy treatments? *
Yes
No
Any cancer that requires chemotherapy, radiation, bone marrow treatments, and/or cell therapy treatments? *
Yes
No
Kidney failure requiring dialysis treatments? *
Yes
No
High-risk pregnancy or pregnancies involving multiple fetuses? *
Yes
No
Hemophilia, or other blood clotting disorders? *
Yes
No
Is the applicant or any of their dependetns receiving medical care from a doctor currently or has within the past five years been treated for cancer of any kind? *
Yes
No
Has the prospective client or any of his/her dependents, seen a medical provider, had treatment recommended, received care (including prescriptions) or been hospitalized for any of the following within the last 5 years: cancer, heart disease (including Bypass), Heart Attack, Heart Surgery, or Stroke? *
Yes
No
Has the applicant or any of his/her dependents applying for coverage in the past 5 years been home bound or incapacitated or incapable of self-support due to a medical condition? *
Yes
No
Has the applicant or any of his/her dependents applying for coverage, been under the care of a doctor currently or in the past 5 years for Autoimmune or blood disease i.e., Lupus MS, Anemia, AIDS, HIV, Hemophilia, IBS, Crohn's? *
Yes
No
Has the applicant or any of his/her dependents, been under the care of a doctor currently or in the past 5 years for any form of organ support (i.e. dialysis)? *
Yes
No
Has the applicant or any of his/her dependents applying for coverage, been under the care of a doctor currently or in the past 5 years for Organ Failure or Organ Transplant for Kidney, Liver, Lung, Heart and or any form of organ support i.e., dialysis? *
Yes
No
Is the applicant or any of his/her dependents applying for coverage currently pregnant or expecting? *
Yes
No
Has the applicant or any of his/her dependents applying for coverage, currently being treated for condition(s) you have been hospitalized for in the past 5 years? *
Yes
No
Has the applicant or any of his/her dependents applying for coverage, been under the care of a doctor currently or in the past 5 years for respiratory disorders, Emphysema, Chronic Bronchitis, COPD or Chronic Pneumonia? *
Yes
No
Has the applicant or any of his/her dependents applying for coverage, been under the care of a doctor currently or in the past 5 years for musculoskeletal disorders i.e. Back Disorders, Muscular Dystrophy, Cerebral Palsy, Dermatomyositis, Compartment Syndrome, Sciatica or Osteoporosis? *
Yes
No
Has the applicant or any of his/her dependents applying for coverage, been under the care of a doctor currently or in the past 5 years for substance abuse or substance dependency? *
Yes
No
Has the applicant or any of his/her dependents applying for coverage, been under the care of a doctor currently or in the past 5 years as a Type 1 Diabetic? *
Yes
No
Has the applicant or any of his/her dependents applying for coverage, been under the care of a doctor currently or in the past 5 years for a previous major surgery? Or have an upcoming planned surgery? *
Yes
No
Is the applicant willing to share personal health and consumer insights data through short questionnaires throughout the year? *
Yes
No
Submit Application
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