Your answers to the questions below will help us determine how Americare can best help you.


Assessment Questionnaire 
1. If you could add one health care service to supplement your health insurance, what would it be?




2. Ideally, I would like to address this challenge.




3. We would like to add other health service options, including:
Number each one by priority: 1 highest priority to 4 least priority.
Provide wellness-management programs customized to meet individual needs.
               For example: controlling diabetes or reducing cholesterol.
Determine more ways to mitigate health-related incident risks.
Organize, manage and store secured electronic health records.
Other:




Company/Organization Name:
Contact Name:
Number of people/employees:
   
Contact Preference:  
At least one contact is required.  
Email:
Phone:
Mail:
 
Which applies to you: Corporation
Association
Individual
School
Foster Care








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