MightyWELL Health CarePlus Application
Information provided is to design a Custom Healthcare Plan for preexisting conditions.
*
I Acknowledge
Primary Applicant Name
*
First Name
Middle Name
Last Name
Suffix
Company or Group Name
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Health Questions
Health Questions Please explain YES answers below.
*
Yes
No
Are you or any applicant currently seeking treatment or taking any medications?
Within in the past 24 months, has any applicant been examined, diagnoses, or treated for any illness, disease, or injury?
Are you or any applicant currently experiencing any symptoms of illness or have within the past 24 months.
Please explain YES answers below
Applicant
*
Primary
Spouse
Child
Name of Applicant
*
Age
*
Social Security Number
*
Required for MIB report
Please explain in detail any medications being taken, preexisting conditions, or any symptoms.
*
Applicant
Primary
Spouse
Child
Name of Applicant
Age
Social Security Number
Required for MIB report
Please explain in detail any medications being taken, preexisting conditions, or any symptoms.
Name of Applicant
Age
Required for MIB report
Social Security Number
Required for MIB report
Applicant
Primary
Spouse
Child
Please explain in detail any medications being taken, preexisting conditions, or any symptoms.
MightyWELL Representative
Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Signature
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: