Please see the uninsurable medication and conditions list before continuing. Please note certain drop down selections will open additional fields. To proceed to the health pre-screen, select the health dropdown and choose “I would like to do a pre-screen”. If you have any questions regarding this form, please contact our office at (866) 605-7437.
*Generic versions also uninsurable
Activity of daily living deficits (need help with any of the ADL’s)
Amyotrophic Lateral Sclerosis (ALS)
Balance disorder/ Gait impairment
Depression (severe or hospitalized in the last 5 years)
Drug addiction/illicit drug use (within last ten years)