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Individual LTC CASH™ Prequalification

Start the Process

Simply fill in the following required information and answer 4 easy questions. Submit the form and you will have begun the prequalification process.

*ALL STARRED form fields MUST be included to process this prequalification application*

*First Name

*Last Name

*Email

*Address line 1

Address line 2

*City

*State

*Zip Code

Telephone Number

*List any medications and major health concerns that you may have. Type "None" if this does not apply to you.

Please Answer the Following 4 Questions

1. Have you ever received medical advice, consultation, or treatment for any of the following conditions:

Yes No

Alzheimer's Disease, Lewy Body Disease, Dementia, any memory problems, Psychosis, Schizophrenia, Mental Retardation
Amytrophic Lateral Sclerosis (ALS), Myasthenia Gravis, Multiple Sclerosis, Parkinson's Disease/Parkinsonism
Post-Polio Syndrome, Demyelinating Disease, other neurological conditions affecting the brain or spinal cord
Lupus (SLE), Mixed Connective Tissue Disease, Scleroderma, Muscular Dystrophy, other muscular conditions causing limits
Kidney Disease, Polycystic Kidney Disease, Liver Cirrhosis, Hepatitis, Hemachromatosis
Amputation - due to disease, Double heart valve replacement, Organ or Bone Marrow transplants
Brain or spinal tumors - benign or malignant, Multiple Myeloma
Peripheral Vascular Disease AND Smoking, Peripheral Vascular Disease AND Diabetes, Skin Ulcers AND Diabetes
2 or more Strokes or Transient Ischemic Attacks (TIAs), Single Stroke AND Diabetes, TIA AND Diabetes
AIDS - You need not answer "yes" if you have only tested positive for Human Immunodeficiency Virus (HIV).
In addition, you need not answer "yes" if you do not have or have never been tested for HIV or AIDS.
You are obligated to answer "yes" if you have actually been diagnosed as having AIDS.

2. In the past year have you needed assistance or supervision in performing activities of daily living*, used any medical equipment **, or received nursing home care, home health care, assisted living care, or adult day care services?

YesNo

* Activities of daily living include: bathing, transferring, continence, dressing, toileting, and eating. For Example, an individual may need to be reminded to take medications, to dress properly, or the individual may need someone to standby when he/she transfers from a bed to a chair.

**Medical equipment includes: wheelchair, walker, motorized scooter, quad cane, Canadian crutches, catheters, ventilators, oxygen, stair lift, or home intraveneous medications

3. In the past 2 years have you consulted with a medical professional, had surgery for, been hospitalized for, had therapy or rehabilitation services for, or taken any medication for any of the following:

Yes No

Arthritis with multiple joint replacements or causing limitations
Cancer
Cardiomyopathy or Congestive Heart Failure
Chronic blood disorders
Chronic muscular or neurological conditions
Vascular disease or other circulatory disease
Diabetes
Drug/Substance abuse
Bowel or bladder problems
Falls, fractures, or compression fractures
Joint deformities
Lung disorders such as COPD or Emphysema
Manic-depression
Stroke OR TIA OR Amaurosis Fugax - single episode

4. In the past year have you been hospitalized overnight, been advised to have surgery, received rehabilitative services including physical or occupational therapy, OR have you received disability income or worker's compensation?

Yes No

Once this form is reviewed, one of our professional service representatives will contact you directly.