Apply Eligibility Questions Did you turn age 65 in the last 6 months?*NoYesDid you enroll in Medicare Part B in the last 6 months?*NoYesHave you had coverage from any Medicare plan other than original Medicare?*NoYesAre you covered medical assistance through the state Medicaid program?*NoYesBesides those listed above, have you had coverage under any other health insurance within the past 63 days?*NoYesDo you have another Medicare supplement insurance currently in force?*NoYes Are you dependent on a wheelchair or any motorized mobility device?*NoYesDo any of the following apply to you? Currently hospitalized, confined to a bed, in a nursing facility or assisted living facility, receiving home health care or physical therapy*NoYesAt any time, have you been medically diagnosed, treated, or had surgery for any of the following?A. congestive heart failure, unoperated aneurysm, defibrillator*NoYesB. leukemia, lymphoma, multiple myeloma, cirrhosis*NoYesC. Parkinson's Disease, Lou Gehrig's Disease, Alzheimer's Disease, dementia, multiple sclerosis, muscular dystrophy, cerebral palsy*NoYesD. chronic kidney disease, kidney failure, kidney disease requiring dialysis, renal insufficiency, Addison's Disease*NoYesE. any condition requiring a bone marrow transplant or stem cell transplant, any condition requiring an organ transplant*NoYesF. Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), tested positive for the Human Immunodeficiency Virus (HIV)*NoYesDo you have diabetes?NoYesA. that requires use of insulin*NoYesB. with complications including retinopathy, neuropathy, peripheral vascular or arterial disease or heart artery blockage*NoYesC. with history of heart attack or stroke (at any time)*NoYesD. treated with medication that has been changed or adjusted in the past 12 months because of uncontrolled blood sugar*NoYesWithin the past 36 months, have you been medically diagnosed, treated, or had surgery for any of the following?A. alcoholism, drug abuse*NoYesB. cardiomyopathy, atrial fibrillation, anemia requiring repeated blood transfusions, any other blood disorder*NoYesC. internal cancer, melanoma, Hodgkin's Disease*NoYesD. hepatitis, disorder of the pancreas*NoYesWithin the past 24 months, have you been medically diagnosed, treated, or had surgery for any of the following?A. enlarged heart, transient ischemic attack (TIA), stroke, peripheral vascular or arterial disease, neuropathy, amputation caused by disease*NoYesB. myasthenia gravis, systemic lupus or connective tissue disorder*NoYesC. osteoporosis with fractures, Paget's Disease, arthritis that restricts mobility or the activities of daily living*NoYesD. any lung or respiratory disorder requiring the use of a nebulizer or oxygen, or 3 or more medications for lung or respiratory disorder*NoYesE. any lung or respiratory disorder and currently use tobacco products*NoYesWithin the past 12 months, do any of the following apply to you?A. been advised by a medical professional to have treatment, further evaluation, diagnostic testing, or any surgery that has not been performed?*NoYesB. been medically diagnosed or, treated, or had surgery for a heart attack, artery blockage, or heart valve disorder?*NoYesC. had a pacemaker implanted*NoYesD. had a PSA blood test greater than 4.5 with no history of prostate cancer*NoYesE. had a PSA blood test greater than 6.5 with no history of prostate cancer*NoYesF. had a seizure*NoYesWas your last blood pressure reading higher than 175 Systolic or higher than 100 Diastolic?NoYesWithin the past 24 months if you have been medically diagnosed, treated, or had surgery for any brain, mental or nervous disorder, provide reason and diagnosis:Reason and Diagnosis:Within the past five years if you have been hospitalized, treated at an outpatient facility, or emergency room, provide reason and diagnosis:Reason and Diagnosis: *Note: By clicking submit does not fully complete the application process. Please call 1-855-594-0237.
