Sent to: Aetna  - Cigna - United Healthcare - Humana
Prescreen is a form that requests an opinion from the Insurance carriers, of how a health insurance company would
underwrite you. With the health history you are providing here. Before you apply for coverage.

This will never go on any health record.  It is sent in to the carrier with your initials , not your name, anonymously.
This service is free. Note: all services from Healthy Florida are free, the Insurance carriers compensate us. We serve you.

Name:

Phone:   Best time to call

Email:  Quote@HealthyFlorida.com

Date of Birth       

Treatments & Surgeries

List treatments and any surgeries- Please provide approximate dates (month/year). Past 10 years. Type here:

Medication

Type | Amount | Frequency | Condition | How Long Example: XYX, 5 mg, 2x per day, High blood pressure, 3 years. Type here as per example above

Height ( 5ft 6 inches)        Weight Lbs.      Smoker   Yes    

Pre screen note: Results of the pre screen are not a guarantee of coverage. Determination is made by the Underwriters of each Insurance Company after a regular full application has been submitted and reviewed. Healthy Florida does not charge for this service. Healthy Florida sends this to the Insurance carriers on your behalf. Their opinion /prescreen  is their own and not Healthy Florida’s.

I have read  the results of "Pre screen note" above and understand it content and this is not a guarantee of coverage or an application.
This box must be checked to submit. When submitted correctly you will see a confirmation on screen that it has been received.