Form 5217ut - Utah Universal Small Employer Application - Best Life Page 2
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4E. HEALTH STATEMENT
EACH QUESTION MUST BE CHECKED "YES" OR "NO." ALL questions must be answered and complete or the application will be returned. It is your
responsibility to notify the insurer of any change in health status while this application is pending. The federal Genetic Information Nondiscrimination Act
prohibits health insurers from requesting, requiring, purchasing, or collecting “genetic information” for underwriting purposes. DO NOT REPORT GENETIC
INFORMATION ON THIS FORM. Information about manifested diseases or conditions of an applicant is not considered genetic information and is to be
reported, even if the disease or condition is caused by or associated with genetics. The information provided in this section may be used for rate setting,
risk-adjustment or coordination of care, but will not be used to deny coverage.
HEALTH QUESTIONS
YES
NO
Is any applicant pregnant or financially responsible for an unborn child, or do you anticipate adopting a child in the next 12 months?
If currently pregnant, provide expected due date_________________________.
(mm/dd/yyyy)
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Do you anticipate complications or multiple births?
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Have you had prior complications or multiple births?
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Within the past 12 months has any applicant:
A. Taken any prescribed medications for any health condition identified in Section E?
B. Been injected with a drug or medication by a health care provider excluding immunizations?
Are all applicants’ immunizations current?
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Within the past 12 months has any applicant used any form of tobacco, including but not limited to cigars, cigarettes, or chewing
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tobacco)? If applicant has quit using tobacco give approximate quit date:__________________________
(mm/dd/yyyy)
Within the past 5 years, has any applicant applying for coverage been tested for or diagnosed with, had treatment recommended,
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received treatment, including prescription medications, or been hospitalized for any illness, injury, or health condition related to any
of the categories listed below?
A. Cardiovascular disease or heart attack, stroke, high blood pressure, or any other diseases or disorders of the heart, arteries,
blood, or blood vessels?
B. Asthma, emphysema, tuberculosis, or any other diseases or disorders of the lungs or respiratory system?
C. Diabetes or any other diseases or disorders of the pancreas? If yes, check all that apply:
Non Insulin Dependent
Insulin Dependent
Insulin Pump
D. Hepatitis or any other diseases or disorders of the liver, stomach, colon, or intestines?
E. Chronic kidney stones or any other diseases or disorders of the kidney, prostate, or bladder?
F. Male or female reproductive organs or any other diseases or disorders including infertility?
G. Arthritis or any other diseases or disorders of the joints, muscles, back, or bones?
H. Mental health diseases or disorders or alcohol/drug abuse?
I. Seizures/epilepsy, paralysis, or any other diseases or disorders of the brain or nervous system?
J. Lupus or any other diseases or disorders of the immune system?
Within the past 5 years, has any applicant applying for coverage been diagnosed or treated by a licensed medical professional for
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HIV, AIDS, or AIDS Related Complex?
Within the past 5 years, excluding routine or preventative care, has any applicant applying for coverage been tested for or
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diagnosed with, had treatment recommended, received treatment, including prescription medications, or been hospitalized for any
illness, injury or health condition not indicated above?
7 Has any applicant ever had any organ or tissue transplant?
8 Has any applicant ever had cancer (including skin cancer or melanoma)?
IF ANY OF THE QUESTIONS IN THIS SECTION WERE CHECKED “YES”, PROVIDE DETAILS IN SECTIONS F & G.
F. PRESCRIPTION INFORMATION WITHIN LAST 12 MONTHS Refer to Section E
IF ANY OF THE QUESTIONS IN SECTION E WERE CHECKED “YES”, PROVIDE DETAILS IN THIS SECTION. Attach a separate sheet if necessary.
Name of
Reason for medication (Name of Illness,
Start Date
End Date
Physician, clinic, or hospital name. If
Name of Medication
Applicant
Disorder or Treatment)
MM /YYYY
MM/YYYY
known, provide phone number or address.
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
Page 2 of 4
Utah Small Employer Health Insurance Application October 2010
Form 5217UT (Rev. 10/10)
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