Florida Health Care Plans Addendum To Group Application Form

ADVERTISEMENT

FLORIDA HEALTH CARE PLANS
ADDENDUM TO GROUP APPLICATION
2 - 9
Health Questionnaire for Groups Enrolling
Eligible Employees
Health History for Individuals and Their Dependents.
The following information is confidential and will not be seen by or given to
ALL of the questions must be answered by you or your application will be returned. Incomplete applications may delay the
your employer.
effective date of your coverage.
Employee Name ___________________________ SSN ____________________ Group Name _________________________________
Has anyone on this application consulted with or been examined or treated by any health care professional during the last 10 years for any illness,
injury, or health condition in any of the categories listed below? If yes, please check the box that most appropriately describes the problem and
explain fully below. Please note that, if you leave out or misrepresent information, we may terminate or not renew your coverage, or we may
change your premium retroactive to the date your policy became effective.
Breast
Colon
Leukemia
Testicular
Brain
Ovarian
Lymphoma
Cervical
Liver
Lung
1 Cancer
_
Yes
No
Melanoma
Prostate Stage ____
Other __________________
2 Heart/Circulatory
Aneurysm
Bypass
Angioplasty/Stent
Congestive Heart Failure
Elevated Cholesterol/Triglycerides
Yes No
Heart Disease
High Blood Pressure
Stroke
Angina
Hemophilia
Blood Clots
Pacemaker
Blood
Disorder
Sickle Cell Anemia
Heart Attack
Heart Murmur
Chest Pain
Anemia
Varicose Veins
Other ___________________________________________________
3 Reproductive
Current Pregnancy (due date__________)
Multiples (#__)
Pregnancy Complications
Menstrual Disorders
Yes No
Breast Disorders
Endometriosis
Infertility
Fibroids ____________
Other __________
4 Intestinal/Endocrine
Chronic Pancreatitis
Colon Disorder
Crohn’s
Hepatitis B/C
Reflux
Liver Disorder
Ulcer
Yes
No
Ulcerative Colitis
Growth Hormones
Diabetes
Cirrhosis
Other_____________________
5 Brain/Nervous
Alzheimer’s Disease
Parkinson’s Disease
Cerebral Palsy
Migraines
Multiple Sclerosis
Tumor
Yes No
Head Injury
Cyst
Paralysis _________
Seizures/Epilepsy ______________
Other ______________
6 Immune
Scleroderma
ALS ______
Rheumatoid Arthritis ___________________
Psoriasis __________
Yes No
Lupus ________
Immuno Deficiency _______________________________ Other _________________
7 Lung/Respiratory
Allergies
Asthma
Cystic Fibrosis
Emphysema
Sarcoidosis
Lung Disorders
Tuberculosis
Yes No
Sleep Apnea
COPD
Other _________________________________________________________
8 Eyes/Ears/Nose/Throat
Acoustic Neuroma
Deviated Septum
Cataracts
Glaucoma
Cleft Lip/Palate
Retinopathy
Yes
No
Other___________________________________________
9 Urinary/Kidney
Chronic Kidney Stones
Kidney Disorders
Bladder Disorders
Polycystic Kidney Disease
Prostate Disorder
Renal Failure
Chronic Kidney Disease (CKD)
Other __________________________________________
Yes
No
10 Bones/Muscles
Osteoarthritis
Knee Disorder
Bulging/Herniated Disc
Joint injury
Fibromyalgia/CFS
Spina Bifida
Yes
No
Back Disorder
Neck Disorder
Shoulder Disorder
Chronic Lower Back Pain
Other ________________
11 Behavioral Health
Anxiety/Depression
ADHD
Bipolar/Manic Depression
Schizophrenia
Suicide Attempt
Inpat ETOH/Drug
Yes
No
Inpat MH Hosp
Autism ________
Eating Disorder _________________
Other _________
12 Transplant
Bone Marrow
Organ
Transplant Complications
Discussed Possible Future Transplant Year _____
Yes
No
Stem Cell ____________________________________
Other _____________
Current Medications Please List Meds_________________________________________________________
13 Medication
Medications Taken Within The Past Year
Yes
No
Please List Meds ____________________________________________________________________________
14 Other
Abnormal Test Or Physical Results
Condition Not Mentioned Above
Treatment Or Surgery Discussed Or
Advised
Pending Test Results
Inpat Hosp/Surg in Past Yr.
Pending w/c claim
Tests Advised or
Yes
No
Recommended
Refer to Specialist
Disability
15
Physical deformity, defect
Please List_______________________________________________________
or congenital problem?
16 Alcohol Usage
Yes
No
You
Spouse
Advised to seek treatment? _________________________
17 Tobacco Usage
Tobacco products, including cigarette, pipe, cigar, or chewing tobacco?
Yes
No
If Yes, check applicable boxes: Employee
Spouse
18 Diabetes
If yes, list date of diagnosis: ____/___ /___ (month/day/year) Insulin dependent Non-insulin dependent
Yes
No
19 HIV
Has any person listed on this enrollment form been tested positive for exposure to the HIV infection or been diagnosed
as having ARC or AIDS caused by the HIV infection or other sickness or condition derived from such infection?
Yes
No
MED UW EE 11/07

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 2