Change Request Form (Page 2 of 2) in pdf

Change Request Form Page 2

MEDICAL MANAGEMENT*

Medical Conditions (please check Yes or No)

Has any person added been advised that hospitalization or surgery is needed or anticipated?

 Yes

 No

Has any person added in the past two (2) years been diagnosed, received treatment, or had medication prescribed for, but not limited to, the

following conditions: Cancer; Stroke; Diabetes; Heart or Vascular Disease; Mental or Emotional Disorder; Muscular or Systemic Disease (Arthritis /

Lupus); Alcohol / Drug Abuse; Liver; Kidney; Lung or Intestinal Disorder; AIDS / HIV?

 Yes

 No

Covered Member

Illnesses or Conditions

Date of Diagnosis, Medication,

Treating Physician’s Name

(Full Name)

Treatment or Prognosis

*Information held solely by SIHO Medical Management to ensure quality and coordination of care for members.

To the best of my knowledge, all of the above information is believed by me to be true.

___________________________________________________

_______________________________

Signature of Employee

Date

417 Washington Street

032012C

Columbus, IN 47201

800-443-2980

Change Request Form Page 2