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Individual Healthcare Intake

Individual Healthcare Form

Please complete the information below to the best of your ability. The information provided by you is helpful in determining which plan will best meet your needs in the upcoming plan year. As you are aware, this information is critical in allowing us to review options and find the best fit for you.
  • Date Format: MM slash DD slash YYYY
  • Full Rx Name (brand or generic)DosageFrequency 
    Example: Lisinopril (generic), 20mg, 1x per day
  • NameSpecialtyLocationPhone 
    Example: Dr. John Doe, Cardiology, Plantsville, 860-123-4567
  • ELECTRONIC SIGNATURE

    PLEASE TYPE YOUR FIRST AND LAST NAME
  • Date Format: MM slash DD slash YYYY
  • If you have any questions regarding this form, please contact Lighthouse at 800.344.3531

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