ENROLLMENT IS FREE
FILING A CLAIM IS FREE

Welcome to the only E-Care Plan in the USA that pays you a refund for the purchases of your alternative remedies, medicines and supplements. You must have current health insurance to qualify.
You will be given Medical Care using the latest in Tele-Medicine techniques of communications.

There are No Costs, No Fees and No Risks to you. Our mission is your health and wellness.

Your information is protected by Medical Privacy Laws and stored in our EMR, HIPAA compliant, secured and encrypted servers. We refer you to our Privacy Policy Link found at the bottom of this page for a complete review of our strict policies.

Once completed, your information is accessible to you and may be up-dated as needed.

Our Medical Staff asks that your answers are specific as to your diagnosis, any chronic conditions, use of prescriptions, and alternative/ integrated medicines, drugs or supplements.

Also, please make note of your Username, Password, and Membership I.D. number.

WELCOME to the US Tele-Medicine E-Care Plan,
That Pays to Promote Health

* denotes required fields

1. Enter member information:

Email*

Password*

Re-type Password*

Reminder Question*

Answer*

2. Personal Information

First Name*

Middle Name

Last Name*

Date of Birth

Mo* Day* Year*

Marital Status*

Sex*

Street Address*

City*

State*

Zip*

Phone*

3. Insurance Information

Insurance Company*

Insurance Company Address*

Insurance Member ID

Insurance Plan or Group Number

Patient Named Insured?*

Relationship to named insured
First Name of the named insured
Middle Name of the named insured
Last Name of the named insured
Named insured date of birth	Mo: Day: Year:
Marital status of named insured
Sex of named insured
Street Address of named insured
City
State
Zip
Phone

4. Patient Wellness Information

For the following set of questions, choose the number that best describes your current circumstances on a scale from 1 to 5. 1 being normal to 5 being chronic discomfort.
Appetite*	1 2 3 4 5
Balance*	1 2 3 4 5
Breathing/Resipiratory*	1 2 3 4 5
Concentration/Focus*	1 2 3 4 5
Energy Level*	1 2 3 4 5
Eye Sight*	1 2 3 4 5
Libido*	1 2 3 4 5
Muscle Pain*	1 2 3 4 5
Pain*	1 2 3 4 5
Flexibility*	1 2 3 4 5
Sitting*	1 2 3 4 5
Skin Condition*	1 2 3 4 5
Sleeping*	1 2 3 4 5
Standing*	1 2 3 4 5
Staying Alert*	1 2 3 4 5
Walking*	1 2 3 4 5
Please list any allergies you have
Do you use presciption drugs?*

Do you use alternative supplements?*
Examples include: Vitamins, Herbs, Protein Based, Amino Acids, Nutritional Blends, Bio-Hormones, Minerals, Weight Loss Supplements, Amino Acids, Energy Supplements, Multi-Vitamin Blends, Natural Skin Care Products, , Antioxidants, Sports Nutrition, Enzymes, Nutraceuticals

You will be prompted via e-mail to complete this questionnaire again in 6 months. Over time, you will have assembled a record of your wellness, which you may then print, and share with your primary physician. Our Privacy Policy protects this information.

5. Doctor Information
Doctor's Last Name
Doctor's First Name
Doctor's NPI Number what's this?
Diagnosis*
Detailed Diagnosis

You must agree to our terms

If Yes, please list them:
Name of supplements	Dosage per day





Rate the relief of your symptoms after medicating with your daily dosage of supplements.*	Unsure Same Better Worse

ENROLLMENT IS FREE FILING A CLAIM IS FREE

ENROLLMENT IS FREE
FILING A CLAIM IS FREE