Form Gr-69209-14 - Ohio Employee Enrollment/change Form - Aetna Page 4
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5H. Health questions (Continued)
Has any person listed on this enrollment form tested positive for exposure to the human immunodeficiency virus (HIV) or been
2.
diagnosed with acquired immune deficiency syndrome (AIDS) caused by HIV or other sickness or condition derived from this
Yes
No
infection? Or has any person listed on this enrollment form been diagnosed with AIDS-related complex (ARC)?
Is anyone currently pregnant? Due date
Check applicable boxes:
3.
Yes
No
C section planned
Multiple births expected (Number
)
Complications:
Past or
Present
4. Has anyone applying for coverage had more than $5,000 in medical expenses in the past 24 months?
Yes
No
5. Has anyone applying for coverage been prescribed medications in the past 12 months?
Yes
No
6. Does anyone applying for coverage have a known condition that requires ongoing treatment?
Yes
No
IF YOU ANSWERED “YES” TO ANY OF THE QUESTIONS IN SECTION H, YOU MUST COMPLETE SECTIONS I and J.
I. Health questionnaire – Details for “Yes” answers in Section H.
List all individuals enrolling for coverage.
Currently taking
Cigarette
prescription
Name
Age
Height
Weight
smoker
medication(s)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
J. Provide details below to any boxes checked above.
(If additional space is needed, attach a separate sheet and be sure to sign and
date the sheet.)
Date
Names of
Ques.
Condition / diagnosis /
Date of
treatment
prescription
Still taking
No. Name
treatment
Dosage
onset
ended
medication
medication
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
4
OH
GR-69209-14 (4-16)
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