MyAssureHealth.com Web Onboarding

Full Name*

First Name

Last Name

Phone Number*

Email Address*

State*

Do you have health insurance?*

Yes No

Do you have Original Medicare as your primary health insurance?*

Yes No

Do you have secondary insurance, such as a Medicare supplement?*

Yes No

Do you have Medicare Advantage?*

Yes No

What insurance company do you have your Medicare Advantage plan through?

What insurance company do you have your coverage through?

If you know it, what is the name of your secondary insurance company. If you don’t know, you can skip this question.

Do you have any of the following conditions?*

Diabetes Hypertension Obesity High cholesterol Heart disease Other