Wellory: Qualification Survey

1
What's your email address?* This field is required.We'll use this to contact you about your eligibility to meet with an in-network dietitian.
example@example.com
2
What's your name?* This field is required.Please write your full name as it appears on your insurance card.
First Name
Last Name
3
In what state do you currently reside?* This field is required.Your physical location determines which of our providers are eligible to support you.
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
I'm outside the USA
4
Which of the following best describes the reason(s) you'd like to meet with a nutrition provider?
My BMI is between 25-30
My BMI is over 30
I have prediabetes
I have diabetes
I have high cholesterol
I have high blood pressure
I have a chronic disease
I have kidney disease
I have an autoimmune condition
I have an eating disorder
I want to learn how to eat healthier
Other
5
For what other reason(s) you would like to meet with a nutrition provider?
6
What health insurance do you have?Please select your primary health insurance.
Aetna
Blue Cross Blue Shield
Cigna
Emblem Health
Healthfirst
Healthpass
Humana
Medicare
Medicare Advantage
Medicaid
MVP
Oxford
Oscar
United Health Care
Other
I don't have health insurance
7
What health insurance do you have?Please select your primary health insurance.
Aetna
Blue Cross Blue Shield
Cigna
Emblem Health
Healthfirst
Healthpass
Humana
Medicare
Medicare Advantage
Medicaid
MVP
Oxford
Oscar
United Health Care
Other
I don't have health insurance
8
What other health insurance do you have?
9
What other health insurance do you have?
10
What type of plan do you have?You can find this information on the front of your insurance card.
PPO
HMO
POS
Open Access
Open Access Plus
LocalPlus
EPO
HDHP
Other
11
What other type of plan do you have?You can find this information on the front of your insurance card.
12
What is your Member ID?You can find this information on the front of your insurance card.
13
Are you at least 18 years of age?
No
Yes
14
What is your date of birth?Your birthdate allows us to verify your insurance benefits.
Date
Month
Day
Year
15
How did you hear about Wellory?By submitting this form, you are opting into email communication with Wellory.
Doctor Referral
My Company
Friend or Family
News or Article
Email Newsletter
Facebook
Instagram
Twitter
LinkedIn
White House National Nutrition Strategy
Other
16
What company do you work for?
17
From what other source did you hear about Wellory?
Should be Empty: