Personal Health and Fitness Proposal Request

To request a Personal Health and Fitness Proposal, go to the form below and complete it. Then, click on the “Submit” button to tell us what you want. No cost. No obligation.

Our program is unique. While the health plan is the centerpiece, it is only a part of our multi-component system. For individuals, our advocacy and assistance programs will help you better manage your personal and family healthcare affairs in less time and at lower cost.

Our plan can also help employers build a workplace Fitness Culture while promoting employee capabilities and productivity.

If you have questions or need additional information, go to our Contact Us Page.

Please note that all fields followed by an asterisk must be filled in.

Will your Total Health & Fitness Plan apply to an individual or a family?:*
Will your Total Health & Fitness Plan apply to an individual or a family?:*

	Individual;
	Family.

Complete and submit this form to provide your preferences to help us design and develop the health & fitness programs that will best serve you. Please indicate the number of adults:*
Complete and submit this form to provide your preferences to help us design and develop the health & fitness programs that will best serve you. Please indicate the number of adults:*

Please indicate the number of minor dependents:*
Please indicate the number of minor dependents:*

Please indicate the total number of family members, then, in the following name and address fields, please give contact information for the primary family member:*
Please indicate the total number of family members, then, in the following name and address fields, please give contact information for the primary family member:*

First Name*
First Name*

Last Name*
Last Name*

E-mail Address*
E-mail Address*

Street Address*
Street Address*

City*
City*

State/Prov*
State/Prov*

Zip/Postal Code*
Zip/Postal Code*

Country*
Country*

Home Phone*
Home Phone*

MEDICAL SELF CARE PLAN: A low-cost, online information service that helps you make good decisions about your medical needs, about the appropriate use of medical services, about being an informed healthcare consumer and about managing your costs for medical services. For more information, go to the Medical Self Care Plan page:*
MEDICAL SELF CARE PLAN: A low-cost, online information service that helps you make good decisions about your medical needs, about the appropriate use of medical services, about being an informed healthcare consumer and about managing your costs for medical services. For more information, go to the Medical Self Care Plan page:*

	Yes - Include these services in my Health and Fitness Plan proposal;
	No - I do not need or want these services.

PERSONAL FITNESS PLAN: A low-cost, online comprehensive and interactive personal health risk assessment and fitness program that improves health, stimulates a fitness mindset and promotes the wellness culture that improves your lifestyle and longevity. For more information, go to the Personal Fitness Plan page:*
PERSONAL FITNESS PLAN: A low-cost, online comprehensive and interactive personal health risk assessment and fitness program that improves health, stimulates a fitness mindset and promotes the wellness culture that improves your lifestyle and longevity. For more information, go to the Personal Fitness Plan page:*

	Yes - Include these services in my Health and Fitness Plan proposal;
	No - I do not want or need these services.

PATIENT CARE PLAN (For individual members and their immediate families): A low-cost information, advisory, assistance and advocacy service covering the healthcare system to help you better mind your healthcare affairs. Access is online or by telephone. Patient Care services will tell you what you need to know, advise you on what you need to do, help you do what needs to be done, and, if necessary, do it for you. For more information, go to the Patient Care Plan page. (Note: The focus of Medical Self Care is medical issues. The focus of Patient Care is healthcare system issues.):*
PATIENT CARE PLAN (For individual members and their immediate families): A low-cost information, advisory, assistance and advocacy service covering the healthcare system to help you better mind your healthcare affairs. Access is online or by telephone. Patient Care services will tell you what you need to know, advise you on what you need to do, help you do what needs to be done, and, if necessary, do it for you. For more information, go to the Patient Care Plan page. (Note: The focus of Medical Self Care is medical issues. The focus of Patient Care is healthcare system issues.):*

	Yes - Include these services in my Health and Fitness Plan proposal;
	No - I do not need or want these services.

PATIENT CARE PLAN (Extension for family elders): Members who subscribe to the Patient Care Plan for themselves and their immediate family members have the option, at additional cost, to extend Patient Care Plan services to family elders for whom they have, or in the future may have, caregiver responsibilities. Patient Care services for elders can include additional services that apply to caregivers and seniors. For more information, go to the Elder Care Plan page:*
PATIENT CARE PLAN (Extension for family elders): Members who subscribe to the Patient Care Plan for themselves and their immediate family members have the option, at additional cost, to extend Patient Care Plan services to family elders for whom they have, or in the future may have, caregiver responsibilities. Patient Care services for elders can include additional services that apply to caregivers and seniors. For more information, go to the Elder Care Plan page:*

	Yes - Include these services in my Health and Fitness Plan proposal;
	No - I do not need or want these services.

Please indicate the number of family elders to be included:*
Please indicate the number of family elders to be included:*

Please enter the word that you see below.

Request A Personal TotalHealth and Fitness Proposal

Request A Personal Total
Health and Fitness Proposal