Private Pay / Non-Insurance Program Application

Apply for the Colorado private pay / non-insurance hypertension program.

This program is for Colorado patients who want private pay hypertension management for $100/month with a one-year agreement.

Privacy note: Please do not submit Social Security numbers, insurance ID numbers, full medical records, or emergency medical requests through this form.

First name *

Last name *

Email *

Phone *

City in Colorado *

State *

Have you been diagnosed with high blood pressure? *

Do you have a PCP?

Do you currently have a BP monitor?

Are you currently taking BP medications?

What are your blood pressure goals or concerns?

I confirm I am located in Colorado or seeking services while located in Colorado.

I understand this is a private pay / non-insurance program costing $100/month with a one-year agreement, paid by credit card through Stripe, and that insurance is not billed for this program.

I understand this is not emergency care and does not replace emergency services.