LTC Pre-Qualifiction Health Form

If you would like us to do this preliminary review on your behalf, with absolutely no cost or obligation on your part, please either fill out the form below and click on Submit, or print it here.  If you choose to print out the form, you may scan and email it to us (, fax it [1-412-774-1980], or snail mail it (Futurecare Associates, Inc. 302 Butternut Court Pittsburgh, PA 15238).  Please include your phone number or email address.

Basic Information

If yes, please complete a separate form for your spouse

Personal Information

If yes, please provide details below.

If yes, please provide details below.

Please provide details for any of the above.