Employee Application and Medical Health Questionnaire

Transcription

1 Smith, Charles: Employee Application and Medical Health Questionnaire For individuals in Groups with 1-19 eligible employees Please return entire application form to: (incomplete forms will be returned) Group Services, Inc. P.O. Box Cleveland, OH Phone: (216) (800) Fax: (216) *Important Note: Please be sure to submit applications immediately to avoid late entrant penalties imposed by insurance carriers! Please print application with a ballpoint pen. Thank you. If you do not want any coverage OR if you decline some of the coverage options but request others, please complete this waiver (Please Print) A. Waived Coverages: I do NOT want (Check One) Health and Life/Disability through Medical Mutual, Fort Dearborn Life Insurance, or Kaiser Permanente Health through Medical Mutual or Kaiser Permanente Life/Disability through Fort Dearborn Life Insurance Health for the following spouse and dependents only: Please indicate in Section B reason for waiving coverage for dependents. 1) 2) 3) 4) 5) B. Current Health Coverage Status: I have (Check One) Waiver No Coverage Other Coverage Spousal Coverage Other Insurance Company Name: C. Authorization: The terms of this waiver are explained in Section 7 of this application. I have read and understand those terms. Current Employer: Employee Date Of Birth: Print Employee Name: Employee Social Security #: Print Spouse Name: Spouse Social Security #: Signature: Date: Warning: If you or your family members are covered by more than one health care plan, you may not be able to collect benefits from both plans. Each plan may require you to follow its rules or use specific doctors and hospitals, and it may be impossible to comply with both plans at the same time. Before you enroll in this plan, read all of the rules very carefully and compare them with the rules of any other plan that covers you or your family. (Ohio Admin. Code Section ) The Explanation of Waiver I understand that if I check any box in Question A of the Waiver on the front cover of this application OR check "NO" under any coverages offered in Section 5, that I am choosing not to have those persons covered under the health, life or disability insurance designated, and any later application for enrollment and acceptance will be subject to all underwriting requirements. APP95008 Z2791 R4/05 Page 1 of 4

2 Smith, Charles: MM Group # (as it appears on your ID card) Insurance Application/Policy Change GSI Chamber Membership # (as it appears on your group premium billing) 1. (Please Print) About You and Your Job Company Name/Employer Last Name Social Security Number ABC Company Smith Occupation/Job Title First Name M.I HR Manager Charles T Original Date Of Hire Street Address State Road Full Time Date Of Hire Or Rehire City State Zip Code Cleveland OH Employment Status: Active Not Active Marital Status: Single Married Sex Date Married Active Retired COBRA Separated Divorced Widowed Mor F 08/14/1998 / / Business Phone Home Phone Date Of Birth ( ) Ext ( ) 03/12/1970 / / 2. (Please Print) What You Want Done A. Check the employer offered benefits you want: MEDICAL MUTUAL SuperMed Plus Multiple Option* 100 Plan 90 Plan 80 Plan SuperMed Plus 250/ / / / /4000 HSA s Plus: SuperMed Plus HSA 2500/100 SuperMed Plus HSA 3000/100 SuperMed Plus HSA 4000/100 SuperMed Plus HSA 5000/100 HMO Health Ohio* Medifil SuperMed Classic Gold 250/ / / /2000 Prescription Drug Card *Prescription Drug Card Included Prescription Drug Card not available KAISER PERMANENTE: High Standard Basic Medicare Plus with Dental VISION SERVICE PLAN: Option 1 Option 2 CIGNA DENTAL Basic Dental HMO High Dental HMO Facility #: Basic Dental PPO Medium Dental PPO High Dental PPO 3. (Please Print) You and Your Dependents A. Add Change Delete SELF Spouse 06/01/2000 csmith@ .com Covered Dependents (Legal Dependents) First Name Last Name (If Different) Social Security # Date of Birth 4. (Please Print) Your Other Health Insurance and Medicare B. Action Needed: COBRA: Effective Date Ohio Continuation Law: Effective Date Add Dependent To Policy (list dependents in section 3) Delete Dependent From Policy (list dependents in section 3) Benefit Change (indicate new choice to the left) Name Change: Former Name: Address Change Terminated Employment: Date Request Cancellation: Date Deceased: Date Other: A /12/1970 / / Dr. Robert Jones/Lakewood, OH M 165 lbs. Y A /01/1970 / / Dr. Melissa Clark/Fairview Park, OH F 120 lbs. N 1 Child 2 Child 3 Child A A A Daniel W Smith Emily Smith /04/2000 / / 10/23/2002 / / 03/20/2005 / / Dr. Michael James/Cleveland, OH Dr. Michael James/Cleveland, OH Dr. Michael James/Cleveland, OH F M F 3' 2" 2' 2" 50 lbs. 32 lbs. 16 lbs. N N N / / B. If you have any dependents, other than your spouse, who are over the age of 23 and disabled, designate YES with a "Y" and attach the Certificate of Disability. A blank space = NO C. Relationship to You: C = Child, SC = Stepchild, AC = Adopted Child*, O = Other* (*attach legal documentation) Primary Care Physician/Facility For HMO Health Ohio Only Self Spouse N N N N N N Other Coverage No Coverage Are you or any dependents keeping other health or dental coverage? YES NO If Yes, complete the section below. What date did your most recent health insurance or health benefit program become effective (check box if no prior/current coverage)? / / 01/01/2005 What date did/will the above health insurance or health benefit program terminate? / / 01/01/2006 Name of Policy Holder Name and Address of Other Insurance Company Policy Number Effective Date Coverage Types Work Status Policy Type Medical Dental Active Single Charles Smith /01/2005 / / Hospital Only Vision Retired Family North Point Tower, 1001 Lakeside Avenue, Suite 100 Prescription Drugs Sex (M or F) Height (feet - inches) Charles T Smith 5' 10" Rebecca W Smith 5' 6" Michelle E Smith 3' 6" United Healthcare Weight (lbs.) Smoker Yes or No Medicare Information: { Check and complete if covered by Medicare You Medicare#: Effective Date: Part A: / / Part B: / / Spouse Medicare#: Effective Date: Part A: / / Part B: / / Dependent Medicare#: Effective Date: Part A: / / Part B: / / Reason For Medicare Age Disability End Stage Renal If under age 65, nature of disability Page 2 of 4

3 Employee Name Smith, Charles Employee SS# (Please Print) About your Fort Dearborn Life Insurance Company Plans See Attached for Additional Beneficiary Information Medical Health Questionnaire 6a. 6b. 6c. If your employer offers these additional coverages, please indicate if you would like to enroll in the following. Basic Life And AD&D YES NO Optional Life YES NO (Amount:$ Minimum $10,000, MAX $300,000) (If yes complete evidence of insurability) Dependent Life YES NO Long Term Disability YES NO Short Term Disability YES NO Plan Weekly Benefit Min. Annual Salary Plan Weekly Benefit Min. Annual Salary 1 $100 $7,430 6 $350 $26,000 2 $150 $11,140 7 $400 $29,715 3 $200 $14,860 8 $450 $33,430 4 $250 $18,570 9 $500 $37,145 5 $300 $22,285 If any yes box is checked above, complete the remainder of this section. Class: Annual Salary (excluding bonuses, overtime, and other forms of extra pay) $ 65,000 Beneficiary Last Name Beneficiary First Name Date Of Birth Relationship Benefit Split** Primary Smith Daniel 10/23/2002 / / Child 33 % Secondary Smith Emily 03/20/2005 / / Child 33 % **Unless otherwise noted, if two primary beneficiaries are named, the proceeds will be paid in equal shares to the primary beneficiaries surviving you. Have you, your spouse, or any listed dependent been treated for, diagnosed as having been recommended for future surgery, diagnostic testing or medical treatment or thought you should seek medical advice for any of the following conditions? 6A Cancer Type Leukemia Lymphoma Chemotherapy Radiation LUNG/RESPIRATORY Allergies - shots? Yes No Asthma Cystic Fibrosis Emphysema-oxygen? Yes No Other MUSCULAR/SKELETAL Degenerative Disc Disease Fibromyalgia Herniated disc Osteo Arthritis Rheumatoid Arthritis Other HEART/CIRCULATORY Aneurysm (type ) CAD/Angina Angioplasty (date ) Bypass Surgery (date ) Congestive Heart Failure Heart Attack (date ) Pacemaker/ICD Implant Stroke (date ) Blood Clot Irregular Heart Beat Peripheral Vascular Anemia (type ) Other Blood disorder (type ) Hypertension Blood Pressure Readings 1) 2) 3) High Cholesterol Other Medical Conditions IF YES, PLEASE CHECK THE CONDITION AND EXPLAIN IN SECTION 6C ENDOCRINE Diabetes (type 1-insulin) Diabetes (type 2-oral) Diabetes diet / exercise only Thyroid disorder Other NEUROLOGICAL Cerebral Palsy Epilepsy - Grand Mal Petit Mal Multiple Sclerosis Parkinson s Disease Other PSYCHOLOGICAL Depression Manic Depression/Bipolar Schizophrenia Hospitalized? Yes No (date ) Suicide attempt - (date ) Other Medical Questions (Explain all yes answers in Section 6c) URINARY/BOWEL/REPRODUCTIVE Abnormal Pap (date ) Colon Polyps Crohn s Diverticulitis Enlarged Prostate Gastric Reflux Kidney Stones Ulcer Ulcerative Colitis Infertility Other URINARY/BOWEL/REPRODUCTIVE Transplant (type ) HIV Hemophilia Connective Tissue (type ) Hepatitis- (type ) Other 1) Have you or your dependents been treated for or told that you have any other condition/disorder/disease not listed above? 2) Have you or your dependents been hospitalized, operated on or been advised to have an operation which has not yet been performed? 3) Are you an expectant parent or any of your dependents currently pregnant? If so, what is the due date? 4) Are you or any of your dependents currently taking any medications? If yes indicate medication, reason for taking in section 6C 5) Do any of the conditions identified involve Workmans Compensation? If yes provide the Workers Compensation Case Number: # Explanation Condition Individual s Name Physician s Name/Address Treatment Date (From-To) Diagnosis/Treatment/Prognosis/Medication/Dosage/Reason (be specific) YES NO Kidney Stones Charles T Smith 04/21/ /30/1999 Aenean mollis wisi id tortor. Maecenas eu nulla id ipsum feugiat vestibulum. Morbi ve Vivamus vehicula dapibus lacus. In hac habitasse platea dictumst. Praesent sit amet velit vitae velit adipiscing euismod. Phasellus porta nisl. Suspendis See Attach Attached a separate sheet for Additional in this format Condition if more space Information is required. Page 3 of 4

4 7. The Terms and What You Declare * I hereby apply to the carrier(s) offering the coverage indicated on this application. * I authorize: (1) payroll deductions(s) and remittance of any required contribution for coverage to Medical Mutual (MMO), MHICO, FDL and/or any affiliates or divisions of MMO; (2) release of information, without limitation, from any medical/medically-related facility, government agency or person: (a) to evaluate this application for up to 30 months from the date of this application; (b) to adjudicate claims submitted on behalf of me or my dependents as long as I am covered under this policy; (c) for utilization review programs to monitor health services or quality improvement activities; (d) for credentialing purposes. I authorize the applicable carrier to provide a photocopy of this release to any physician or medical institution to obtain records for the purposes stated above. * I understand: (1) any untrue or incomplete information, statements or answers on this application (whether intentional or not), can result in denial of a claim or recision of coverage and may subject me to legal action by the carrier(s); (2) to be eligible for health coverage, I must be an active full time employee as defined by my employer; (3) I must be actively at work as defined in the group policy to obtain life and/or disability coverage. If I am not actively at work on the date my life and/or disability coverage would become effective, my coverage will not begin until the day I return to work; (4) if coverage is issued, it will be based on full reliance on the information contained in this application; (5) for HMO Health Ohio applicants ONLY full benefits are not provided unless they are provided, arranged and authorized by a Plan Physician and approved by a Plan Medical Director. * I understand: and agree that no agent or broker has the authority; (1) to bind MMO by making promises regarding eligibility, benefits, or the issuance of a policy; (2) to waive any answer or any portion of any answer to any question on this application or any information MMO requests; (3) approve coverage; (4) make or alter any contract on behalf of MMO; or (5) waive or alter any of MMO s other rights or requirements. All contract terms must be in writing and signed or accepted in writing by an authorized representative of MMO to be binding on MMO. * If you select HMO Health Ohio as the Benefits you want in Section 2, Part A, #1, the following provisions apply: 1. The HMO restricts enrollee access to health care providers. No benefits are payable for covered services which are not provided, arranged and authorized by a Plan Physician and approved by the Medical Director. This applies to all covered services except Emergency Services. The HMO will furnish you with a list of plan physicians and plan facilities upon enrollment and/ or request. 2. Right Of Cancellation: If you are obligated to share in the cost of this coverage, you may cancel this application within 72 hours after you have signed this application. Cancellation will occur when written notice is given to Group Services, Inc. Notice of cancellation shall be considered given when you mail a letter to Group Services, Inc. Warning: Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against any insurer, submits any application or files a claim containing a false or deceptive statement is guilty of insurance fraud. (Ohio Revised Code Section ) 8. About Your Needs Employee Name Employee SS# Smith, Charles If you have a special language or other cultural need that may affect the administration of your health plan or health care delivery, please indicate below so that Medical Mutual Of Ohio could better assist you: Hearing-impaired (require use of TDD/TYY or other means of communication) Vision-impaired (require audio communication or large print document) Speak a primary language other than English (require interpretive services) (please list language) Other cultural need/preference 9. Signatures Sign after completing and reading all applicable sections (Including Section 7) I have read all of the statements contained in this application, and declare by signing this application that I am an active, eligible, compensated, full-time employee and that the information I have provided is true and complete to the best of my knowledge. Employee Signature Date Your Spouse s Signature (if applying for dependent coverage) Date Note: GSI collects this data as a service to its members. Completing this form does not cause automatic enrollment. The carrier(s) must approve the application. Please return application form to: Group Services, Inc. P.O. Box Cleveland, OH Phone: (216) Fax: (216) Page 4 of 4

5 Extra Medical Condition Information Treatment Dates Condition Last Name First Name SSN Start End Physician Arthritis, Rheumatoid Smith, Charles: Smith Charles /20/2001 Current Diagnosis: Praesent id nulla et massa feugiat varius. Nulla id metus. Proin eget nulla. Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Treatment: Praesent dui est, vestibulum eget, pretium vitae, vehicula sed, ipsum. Nam luctus, ligula commodo elementum volutpat, tortor augue aliquet nulla, eu tincidunt tellus eros ut lacus Medications/Dosages: Curabitur nunc eros, commodo sed, luctus sed, egestas a, sem. Maecenas tortor tellus, tempus ac, cursus eget, bibendum a, dolor Cras mi felis, scelerisque non, feugiat vel, pulvinar nec, elit. Curabitur ut metus. Aenean tristique dolor id pede. I, or one of my dependents, take medication on a regular basis. Smith Charles /20/ /15/2005 Diagnosis: Class aptent taciti sociosqu ad litora torquent per conubia nostra, per inceptos hymenaeos. Pellentesque habitant morbi tristique senectus et netus et malesuada fames ac turpis Treatment: Cras mi felis, scelerisque non, feugiat vel, pulvinar nec, elit. Curabitur ut metus. Aenean tristique dolor id pede. Etiam aliquet pede. Medications/Dosages: Etiam aliquam libero. Fusce non tortor luctus libero facilisis mollis. Duis wisi purus, imperdiet nec, ornare quis. Please list any additional medications and dosages: Duis quis lorem sit amet wisi vehicula semper I, or one of my dependents, have used tobacco within the last 12 months. Diagnosis: N/A Treatment: N/A Smith Charles N/A N/A Allergies Medications/Dosages: N/A Length of use: Donec id augue vitae dolor tempor placerat Smith Daniel /16/2003 Current Diagnosis: Quisque fermentum, magna a viverra malesuada, velit dolor scelerisque nulla, in porttitor erat augue quis leo. Nulla a leo. Treatment: Nunc porta, nisl vel accumsan luctus, ipsum lectus fringilla eros, eu consequat tortor mauris congue sem. Pellentesque pulvinar erat vel tellus. In nec orci. Ear Disorder Medications/Dosages: Curabitur porttitor turpis. Sed eros dui, tempor et, iaculis eget, tincidunt id, sapien. Donec at massa. Nullam tempus, justo eget facilisis feugiat, nibh wisi porta lorem, sed commodo odio velit in diam. Aliquam nec risus ut magna ultrices blandit. Smith Emily /30/ /17/2004 Diagnosis: Mauris vel tellus a velit varius cursus. Praesent a enim at ante auctor eleifend. In blandit eros Treatment: Vivamus orci enim, mattis nec, egestas a, blandit vitae, nibh. Vestibulum a wisi. Etiam auctor leo at elit. Medications/Dosages: Nam molestie, nulla a commodo varius, ante leo vulputate orci, eget posuere wisi lacus ornare massa. Suspendisse vel sem. Maecenas vel sapien sed leo varius blandit. Nullam auctor nonummy ipsum. Strained or Pulled Muscle Smith Michelle /03/ /05/2004 Diagnosis: Duis pede elit, hendrerit eu, feugiat non, condimentum fermentum, lorem. Suspendisse potenti. Treatment: Sed enim mauris, pharetra eget, commodo in, pellentesque vitae, sem. Prognosis: Donec pulvinar risus et purus. Praesent sem velit, ullamcorper a, dapibus sit amet, mollis pellentesque, tortor. Medications/Dosages: Donec urna wisi, semper ut, porta vel, volutpat at, justo. Proin vel ante dictum nulla placerat sagittis. Vestibulum dapibus euismod lorem. Cras non massa. Vivamus porttitor sem sit amet mauris vehicula rhoncus. I am, or one of my dependents is, currently pregnant. Smith Rebecca /25/2005 Current Diagnosis: Phasellus tincidunt interdum felis. Aliquam porttitor, ligula sit amet hendrerit luctus, nisl turpis faucibus sem, vitae consequat lectus magna eget est. Treatment: Praesent vitae odio. Aenean auctor nunc eu mauris. Curabitur et urna in mi bibendum dapibus. Maecenas id lectus. Vestibulum sagittis augue quis justo. Cras imperdiet fringilla e Medications/Dosages: Nullam massa libero, semper vitae, aliquet viverra, feugiat in, neque. Integer augue. Integer mattis lectus. Fusce nunc nunc, nonummy nec, sollicitudin tempus, auctor Due date: Mauris turpis. Mauris ac dolor sed mauris feugiat tincidunt. Fusce ultricies cursus erat.

6 Extra Medical Condition Information Smith, Charles: Treatment Dates Condition Last Name First Name SSN Start End Physician Within the past 5 years, I, or one of my dependents, have been treated for, or been told that I or one of my dependents has Smith Rebecca /13/ /21/2000 Diagnosis: Ut nunc enim, scelerisque eget, consectetuer id, ullamcorper egestas, magna. Vivamus lobortis lacinia enim. Morbi porttitor erat a eros. Treatment: Ut vel enim convallis mi faucibus sodales. Nunc sapien. Sed ornare, enim varius auctor dignissim, mi odio pulvinar felis, eu laoreet sem nisl at sapien. Medications/Dosages: Aliquam varius. Praesent id dui et enim placerat pulvinar. Pellentesque habitant morbi tristique senectus et netus et malesuada fames ac turpis egestas. Integer sodales, lorem in aliquam bibendum, arcu arcu posuere eros, sit amet gravida urna erat in leo. Extra Beneficiary Information Smith, Charles: Last Name First Name SSN DOB Relationship Type Split Smith Michelle /04/2000 Child Contingent 34 Smith Rebecca /01/1970 Spouse Primary 100