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 (tom@futurecareassociates.com), fax it (412-774-1980), or snail mail it (Futurecare Associates, Inc. 302 Butternut Court Pittsburgh, PA 15238). Please include your phone number or email address.

Personal Information

Client Name^*

Date of Birth^*

Are you married or in a committed relationship?

Is your spouse/partner applying (If yes, please complete separate form)

Address^*

City^*

State^*

Zip Code^*

Email^*

Phone^*

Qualification Information

Are you currently collecting or have you ever collected Disability or Social Securty Disability Benefits?

Have you ever been declined for LTC or Disability Income Insurance?

Are you taking any prescription medications?

Have you been hospitalized in the last 10 years?

Have you received physical therapy in the last 3 years?

Do you have symptoms of, or within the last 10 years, have you received medical advice, diagnosis or treatment, or consulted with a member of the medical profession for any of the following conditions? Select all that apply.

Additional Notes

Additional Comments

LTC Pre-Qualifiction Health Form

Personal Information

Qualification Information

Additional Notes

For Consumers