Health Program Enrollment Application

Please Call Us With Your Questions

Office: (626) 814-0111
336 1/2 S. Glendora Ave. Suite #C West Covina, CA 91790

Member Information

First name

Last name

Date of birth

Please let us know which partner referred you to us?

Contact Information

Best phone number

Best email address

Address

City

State

Zip

Do you give us permission to contact you by Text, Phone, Email, and Voicemail?

Yes No

What is your preferred method of communication?

Please select your Health Insurance Plan Below are the health plans that we currently contract with, If you don't see your plan we offer our group program for $299.

Brand New Day / Molina Health Plan LA Care HealthPlan Cash Member ($299)

Your Insurance Member ID number (If applicable)

Pre Enrollment Questions

What motivated you to apply for this program?

Do you have Diabetes or Pre-Diabetes?

Diabetes Pre-Diabetes I Don't Know?

How long have you had diabetes?

Newley Diagnosed 1 to 5 years 6 to 10 years More than 10 years

Are you having any symptoms of complications?, and when did these begin? (i.e. tell me your brief “story”).

What are the ways your life is impacted by your diabetes? How does diabetes impact your daily life?

What are your greatest fears about your health if things continue the way the are?

Who have you seen for your diabetes (who / what type(s) of practitioner)? MD, Endocrinologist, Dietitians?

What have you tried so far? What helped? What didn’t?

Making significant and sustainable health changes can literally save your life (and certainly transform your quality of life!) And… it will take an investment of time, effort, and income to take on new practices and have the specialist support your need. Are you truly willing to commit to yourself in these ways?

How important on a scale of 1-10 is it to you to address these issues now?

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Health Program Enrollment Application

Please Call Us With Your Questions

Member Information

Contact Information

Pre Enrollment Questions

Please Call Us With Your Questions

Diabetes Care Partners brings you these Health Programs to support your desire for a healthy future to enjoying a lifetime with the people and things you love.