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Step Two:
Get a Custom Plan

Fill out your Pre-Screen Form to Start the Process!

Let’s Start Building Your Plan!

Once you feel like you understand your options and decide to move forward, this is your next step. Submit the Pre-Screen Form below. Then, we’ll reach out to help you choose the right options and build your custom plan.  

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.

Senior couple planning their investments with long-term care advisor

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) 
  • 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

About You


Your Health


Your Spouse


Once You Choose a Plan,
There’s Just One Step Left!

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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.

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