KTA Health+ Inquiry Form

KTA Health+
Thank you for inquiring about our KTA Health+ Program! Please fill out the following form so we may direct you to the appropriate class. Our different classes focus on either diabetes prevention or management. Upon completion, our staff will reach out to you via phone or email.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Email (Optional)
example@example.com
Gender

FemaleMaleOtherPrefer not to say
Have you ever been diagnosed with Type 1 or Type 2 Diabetes? (excludes Gestational Diabetes)*

YesNo
Name of Person Completing this Form*

First NameLast Name

You may qualify for the Diabetes Prevention Program (DPP)!

This year-long lifestyle change program is for those with prediabetes that would like to learn more about healthy habits and changes they can make to reduce their risk of developing Type 2 Diabetes.
What is your primary medical insurance carrier? (If you have Medicare, that is usually primary)

Medicare Part BHMSAKaiserOther

You may qualify for the Diabetes Self Management Education Program (DSME)!

This program is for those who have already been diagnosed with Type 1 or Type 2 Diabetes. It is a 9 week program that teaches you how to manage your diabetes.
What is your primary medical insurance carrier? (If you have Medicare, that is usually primary)

Medicare Part BHMSAUHAAlohaCareOhanaKaiserOther

Thank you for your inquiry!

Unfortunately, we are not currently contracted with your insurance to provide the Diabetes Prevention Program. Please submit your information in this form and someone from our team will reach out with other resources.

If you have any additional questions, please reach out to our Clinical Services team
at (808) 959-2888 or email us at clinicalservices@ktasuperstores.com

Thank you for your inquiry!

Unfortunately, we are not currently contracted with your insurance to provide Diabetes Self-Management Education. Please submit your information in this form and someone from our team will reach out with other resources.

If you have any additional questions, please reach out to our Clinical Services team
at (808) 959-2888 or email us at clinicalservices@ktasuperstores.com

KTA Health+