Health Care Plan Application – 2015

Please note that it is important that you realize that by signing the Health Care Plan Application, you agree to the conditions outlined on our Terms and Definitions page.




Click above to begin downloading the application.  When asked, select Save File, OK.  Please save your application to a place that you will remember (we recommend your Desktop).   Find your saved application and open it.  The application is a fillable form.  Please fill in the blanks.  Do not be concerned with a signature at this time as we will ask for your signature during your first visit.  Save your application using your last name.  For example:  JonesApplication.doc.  Please email your application to


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