Advantage Health

Please complete the following questionnaire

First Name: *

Last Name: *

Phone number to contact you (M-F 8:30-5:00):

Do you currently have a primary care physician?:

Yes

No

If yes, please list his/her name and address::

Do you currently have medical insurance?::

Yes

No

If No, have you recently applied for medical coverage through your local Family Independent Agency?:

Yes

No

If Yes, you did apply for medical coverage, was the coverage::

Approved

Denied

If you were approved, Please list the Name of the Insurance Carrier::