Step Two:
Get a Custom Plan
Fill out your Pre-Screen Form to Start the Process!
Your Pre-Screen Form
The form below is entirely confidential.
Our expert team uses this form to understand which plans you qualify for and which one may fit your situation the best. Once you submit it, we’ll reach out to schedule a meeting to discuss your options.

Before You Submit This Form
Unfortunately, if you are taking certain medications or have been diagnosed with certain conditions, you will be uninsurable. Please refer to the list below to see if this applies to you. If you have any questions or concerns, please contact our office.
Antabuse®, Aricept®, Artane®, Avonex®, Azilect, Betaseron®, Campral®, Cogentin®, Cognex®, Comtan®, Copaxone®, Depade, Donepezil, Eldepryl®, Exelon®, Fentanyl, Galantamine, Hydergine®, Interferon®, Larodopa®/L-Dopa, Lucemyra, Memantine, Methadone, Mirapex®, Namenda®, Namzaric, Parlodel®, Permax®, Razadyne®, Reminyl®, ReVia®, Rivastigmine®, Sinemet®, Suboxone®,
Symmetrelº, Vivitrol®
Some of these medications may be considered if taking for a different reason than normally prescribed.
- Activity of daily living deficits (need help with any of the ADL’s)
- Alcoholism (active)
- Alzheimer’s/Dementia
- Amyotrophic Lateral Sclerosis (ALS)
- Balance disorder/Gait impairment
- Cerebral palsy
- Cirrhosis
- Depression (severe or hospitalized in the last 5 years)Â
- Down syndrome
- Drug addiction/illicit drug use (within last ten years)
- HIV positive
- Huntington’s disease
- Macular degeneration (progressive/wet)
- Memory loss
- Mental retardation
- Multiple myeloma
- Multiple sclerosis (MS)
- Muscular dystrophy
- Organ transplant (except kidney)
- Organic brain syndrome
- Osteoporosis with compression fracture
- Paralysis (paraplegia/quadriplegia)
- Parkinson’s disease
- Pregnancy (current)
- Stroke (multiple or residual effects)
- Surgery pending (will review after)
- Ventricular tachycardia

Pre-Screen Form
Once You Choose a Plan,
There’s Just One Step Left!
3. We’ll Get You Approved
The application process for long-term care plans is complex. You’ll be guided through it to make sure your plan is accepted.