Insurance Qualification - Weymouth Club

Insurance Qualification Form

Please be aware this form does not enroll you in any programs or services. We will follow up with you directly regarding your coverage eligibility. Your information is confidential and will not be shared.

First Name*
Last Name*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Date of Birth*
Phone*
Email*
Marital Status*
Employer*
Health Insurance ID#*
Primary Card Holder's Name and DOB*
Insurance Carrier*
- Aetna
- BCBS
- Harvard Pilgrim Health Care
- Mass General Brigham Health Plan
- Other
If noted other, which insurance do you have?
Medical Conditions
- Pre-Diabetes
- Diabetes
- High Cholesterol
- High Blood Pressure
Height*
Weight*
List Current Medications*

To learn more about our Nutrition and Weight Loss Program BetterFit click here.

Insurance Qualification Form

About

Weymouth Club

Club Hours