Get Health Coverage

Please answer the following questions for yourself, your spouse, and any dependents included in the application for coverage eligibility: 

1. Has the prospective client or any of his/her dependents been under a doctor's care currently or within the past five years for any of the following conditions: cancer, heart disease (including bypass), heart attack, heart surgery, or stroke?
2. Has the prospective client or any of his/her dependents applying for coverage been home-bound, incapacitated, or incapable of self-support due to a medical condition within the past five years?
3. Has the prospective client or any of his/her dependents been under a doctor's care currently or within the past five years for organ failure or an organ transplant involving the kidney, liver, lung, or heart, or for any form of organ support (e.g., dialysis)?
4. Is the prospective client or any of his/her dependents applying for coverage currently pregnant or expecting?
5. Has the prospective client or any of his/her dependents seeking coverage have an upcoming planned surgery?