America's Choice

For each person applying for coverage, have they seen a medical provider, had treatment recommended, received care (including prescriptions) or been hospitalized for any of the following within the last 5 years.

Have you or any of your dependents applying for coverage, been under the care of a doctor currently or in the past 5 years for any of the following conditions: cancer, heart disease (including Bypass), Heart Attack, Heart Surgery, or Stroke? *
 Yes
 No

Have you or any of your 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

Have you or any of your dependents applying for covered, 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

Have you or any of your 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

Are you or any of your dependents applying for coverage currently pregnant or expecting? *
 Yes
 No

Have you or any of your dependents applying for coverage, currently or in the past 5 years been hospitalized, excluding routine childbirth? *
 Yes
 No

Have you or any of your 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

Have you or any of your 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

Have you or any of your 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

Have you or any of your 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

Have you or any of your 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

Once you submit, the last step is to schedule your private appointment.