Form Sb.eesht.10.tx - Employee Enrollment Form

F. Medical History

Employee Name ____________________________ SSN _____________________ Group Name __________________________________

Please answer the following questions for yourself and each person listed in Section B “Family Information” on the first page of this form.

Please answer completely and truthfully. 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. UnitedHealthcare is only seeking to

collect information about the current health status of those persons listed on the application. In answering these questions, you should not

include any genetic information. Please do not include any family medical history information or any information related to genetic services or

genetic diseases for which you believe you or your dependents may be at risk.

Yes

No 1. Is anyone on this application currently pregnant? If “yes” please provide detailed information including anticipated delivery

date, any pregnancy complications, anticipation of multiple births, and/or Cesarean Section.

Yes

No 2. Has anyone on this application visited any health care professional during the last 5 years for any illness, injury, or health

condition? If your answer is "yes" please provide detailed information on next page for each person involved.

Yes

No 3. Has anyone on this application been hospitalized (inpatient or outpatient) or had surgery in the past 12 months? If your

answer is “yes” please provide detailed information on next page for each person involved.

Yes

No 4. Has anyone on this application been prescribed or taken any prescription medications in the past 12 months? If your

answer is “yes” please provide detailed information on next page for each person involved.

Yes

No 5. Does anyone on this application have a health condition, illness, or injury that may require treatment or surgery, or has any

health care professional recommended treatment or surgery for any of you that has not been performed? If your answer to

either question is “yes” please provide detailed information below for each person involved.

Please give details of all “yes” answers above. (If additional space is required, please attach a separate sheet and be sure to date and sign that sheet.)

Question #

Person

Condition/Diagnosis

Treatment/Meds

Physician’s Name Dates Treated Prognosis

Declining coverage due to existence of other coverage:

G. Waiver of Coverage

I understand that by waiving coverage at this time, I will

Spouse’s Employer’s Plan

Individual Plan

not be allowed to participate unless I qualify at a special

I decline all coverage for:

Covered by Medicare

Medicaid

enrollment period or as a late enrollee, if applicable, or at

Myself

COBRA from Prior Employer

VA Eligibility

the next open enrollment period. I also understand that

Spouse

Tri-Care

Dependent Children

pre-existing limitations may apply as explained in the

I (we) have no other coverage at this time

Myself and all dependents

Rights and Responsibilities brochure which I have

Other ____________________________________

received with this form.

Date

Employee Signature if waiving coverage

H. Signature

I authorize UnitedHealthcare Insurance Company and its affiliates ("UnitedHealthcare and Affiliates") to obtain,

use and disclose my medical, claim or benefit records, including any individually identifiable health information contained in these records. I

understand these records may contain information created by other persons or entities (including health care providers) as well as information

regarding the use of drug, alcohol, HIV/AIDS, mental health (other than psychotherapy notes), sexually transmitted disease and reproductive

health services. I authorize any health care provider, pharmacy benefit manager, other insurer or reinsurer, hospital, clinic or other medical

facility, health care clearinghouse, and any of their affiliates, representatives or business associates, to disclose my information to

UnitedHealthcare and Affiliates. I understand the purpose of the disclosure and use of my information is to allow UnitedHealthcare and

Affiliates to make decisions regarding eligibility, enrollment, underwriting and premium risk rating. I understand this authorization is voluntary

and I may refuse to sign the authorization. My refusal may, however, affect my ability to enroll in the health plan or receive benefits, if

permitted by law. I understand I may revoke this authorization at any time by notifying my UnitedHealthcare and Affiliates representative in

writing, except to the extent that action has already been taken in reliance on this authorization. As required by HIPAA, UnitedHealthcare and

Affiliates also request that I acknowledge the following, which I do: I understand that information I authorize a person or entity to obtain and

use may be re-disclosed and no longer protected by federal privacy regulations. This authorization, unless revoked earlier, expires 30 months

after the date it is signed.

I understand that I am completing a joint life and health application and that each response must be complete and accurate. I (we) request the

indicated group medical coverage for myself and, if the plan provides, for my dependents. I authorize any required premium contributions to

be deducted from earnings. I (we) have not given the agent or any other persons any health information not included on the application. I (we)

understand that UnitedHealthcare and Affiliates is not bound by any statements I (we) have made to any agent or to any other persons, if

those statements are not written or printed on this application and any attachments. I have a continuing obligation to report changes in health

status (e.g. received medical advice, diagnosis, care or treatment) after I sign the enrollment form and before receipt of my identification card.

Please maintain a copy of this authorization for your records.

Date

Employee Signature for all applying

Spouse Signature (if applying for coverage)

Page 3 of 4

Form Sb.eesht.10.tx - Employee Enrollment Form - 2010 Page 3

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