Member Enrollment Form
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1 Member Enrollment Form Account Information United Bank for Africa Avon Healthcare Limited Agent s Name Agent s ID Number AVON HMO ENROLLMENT PROCESS 1. Please ll all elds carefully. 2. Select a hospital from the Avon Hospital list applicable to your chosen plan. 3. All forms received by AVON HMO before the 20th of the month will be effective by the 1st of the following month. 4. Forms received after the 20th of the month will be effective the 1st of the subsequent month. 5. If you have any question please call AVON HMO call center or callcenter@avonhealthcare.com PLAN TYPE (Please tick the appropriate box) Boss Plan Premium Life Plan Family Life Plan Couples Plan Life Starter Plan COVER TYPE (Please tick the appropriate box) Self only Self & spouse Self, spouse & dependents PAYMENT DETAILS Amount Paid Date Paid Reference Number PRINCIPAL MEMBER DETAILS Date of Birth: Marital status: Of ce address: Home address: Telephone: Designated next of kin: Address of next of kin: Telephone of next of kin: SPOUSE MEMBER DETAILS Home address: Telephone:
2 Member Enrollment Form (For Individual / Family)
3 Medical Questionaire BIODATA Name: Age: Weight (in kg): Height (in metres): Marital status: Occupation: SINGLE MARRIED MALE WIDOWED FEMALE DIVORCED FOR FEMALES ONLY Are you pregnant? When was your last pregnancy? 0-2 years 3-5 years 6 years and above MEDICAL CONDITIONS DO YOU HAVE / HAVE YOU SUFFERED FROM ANY OF THE UNDERLISTED CONDITIONS Chest pain / Angina or heart attack? Any complications post delivery? If yes, please circle any that pertain to you: Miscarriages Still Birth Dif cult child delivery Any history of irregular menstrual cycle? High blood pressure (hypertension)? Any history of gynecologic procedures or surgery? If yes, please give details Lung/respiratory condition e.g. asthma, bronchitis, emphysema? Stomach / bowel disorder e.g. peptic ulcer or diverculitis or ulcerative colitis? Urinary or kidney disorder e.g. kidney stones, urine incontinence, recurrent urinary tract infections or any requiring dialysis? SURGICAL HISTORY Muscle / bone or joint discorder e.g. bone fractures, osteoporosis, gout or arthritis Have you suffered from any condition requiring surgery in the last six months? Diabetes which is controlled by insulin drugs and / or diet? Prostate disorder? GENERAL QUESTIONS Epilepsy or seizures? Have you ever had or advised to be tested for HIV? Depression or schizophrenia or bipolar or drug or / and alcohol dependency? Have you suffered any of the following unexplained weakness or weight loss or diarrhea or skin lesions or enlarged lymph nodes? Blood disorder e.g. sickle cell anemia or thalassemias or G6PD de ciencies or leukemia? Disease of the eye or nose or throat lasting longer than six months? If yes, please give details Are you currently taking any prescription medications for over 1 month? If yes, what drugs? Cancer that has been partially treated? Congenital abnormalities Had any prescription changed or reduced or stopped or increased? Have you received any new prescription or investigation or new medical consultation in the past 6 months?
4 General Exclusions 1. Any medical services required or injuries sustained as a result of: (a) Naval, military or air force service or operations; (b) Hazardous sports including but not limited to water sports mountaineering, hunting, polo, racing on horseback, rugby, league football, motorcycling or motor racing, riding or driving in any kind of race; (c) Air travel except as a fare-paying passenger in any aircraft licensed for passenger carrying. 2. Any medical services required or injuries sustained as a result of: - War ( declared or undeclared ), riot, strike and civil commotion; or acts of God or acts of terrorism; - Intentional self-injury, suicide or attempted suicide (whether sane or insane), venereal disease, member s own criminal act, intoxication, the use of drugs not prescribed by a physician or injury sustained whilst in a state of insanity, alcoholism or costs resulting from dependency on or abuse of drugs or other addictive substance; - Treatment by chiropractors, acupuncturists and herbalists; - Pregnancy, childbirth, maternity bene ts, abortion, miscarriage, ante-or-postnatal care, caesarean operation where purchased (is subject to twelve months waiting period); - Fertility treatment where purchased (is subject to twelve months waiting period);costs of treatment of infertility related to hormonal imbalance, hormone replacement therapy (HRT) are totally excluded; surgical treatment is limited to one surgery per member lifetime; - Cosmetic or beauty treatment and/or surgery; - Dental treatment unless otherwise stated to be covered by the speci c plan; - Hearing tests or cost of hearing aids; - Any injury, illness or disease speci ed as exclusion and complications caused by a condition that is excluded or follow up treatments or investigations that are due to a condition that is excluded; - Birth defects, congenital illness, autoimmune disorders, sickle cell anemia, conditions and illnesses related to genetic disorders; - Psychiatric illness, mental disorders and/or insanity expenses will be covered up to the sub limit subject to twelve months waiting period; - Any medical treatment required relating to an accident or illness which may have occurred prior to the effective date or to any illness where it was within the knowledge of a Member that he was suffering from it at the effective date; - Treatment of obesity and slimming preparations; - Treatment protocols that are not normal, customary or standard practice within the country; - All expenses associated with HIV/AIDS and related conditions where purchased (subject to twelve months waiting period); - Pre-existing and chronic conditions where purchased (is subject to twelve months waiting period and full declaration on the application at policy inception); - Treatment of hemorrhoids, broids, hernia, and adenoidectomy where purchased (is subject to twelve months waiting period); - All expenses in respect of illnesses/conditions that were subject to waiting periods when the member and dependant joined the scheme; - Upon expiry of the waiting period (s) as indicated above, members will be required to enroll and adhere to Avon HMO s chronic disease management program. These conditions must be declared at the time of application for a member to qualify for the bene t and is subject to Avon HMO s written acceptance. Any newly diagnosed must be noti ed in writing immediately to Avon HMO for you to qualify for the bene t subject to Avon HMO s written acceptance.
5 Declaration Any misrepresentation or non-disclosure of material or factual information will render all bene ts granted by the scheme null and void. In addition, any payment made due to such actions will be recovered from the member by the scheme. General 1. I, the undersigned member: 1.1. Hereby apply for myself to be registered on Avon HMO Scheme and have read, understood and agree to abide by the Rules of the Scheme Warrant that the contents of this application and any other documents which may be required in support thereof are true, correct and complete Understand that the statement and answers provided form the basis of the contracts and any breach of my warranty or non-disclosure of any information material to the assessment of this application shall render any contracts to which this application relates null and void and all premiums paid shall be forfeited; 1.4. Understand and accept that no bene t will be payable by the Scheme unless they are satis ed as to the validity of a claim and have received all requirements which they may deem necessary including the results of such medical examinations and tests that they may require me to undertake Acknowledge and accept that the Scheme reserves the right to cancel membership of the Scheme if any due premium is not paid on the due date. Authority 2. Accepting that I am curtailing my right to privacy but in order to facilitate the assessment of the risks and the consideration of any medical claim, I irrevocably authorize; 2.1. The Scheme to obtain from any person, whom I hereby so authorize and direct to give, any information which the Scheme deems necessary, 2.2. I further authorize and instruct the Scheme and any hospital concerned to give away information relating to myself to the Medical Case Managers appointed by the Scheme I understand and accept that the above authorization constitute a partial waiver of and my right to privacy. Signature of Member Date
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PATIENT REGISTRATION FORM RONALD J ESCUDERO, MD, FACS Please print clearly and fill out completely Patient Legal Name Birthdate Age Address Social Security # City ST ZIP Email Phone Numbers ( ) Home (
Tracy Blum Physical Therapy, Inc NEW PATIENT REGISTRATION FORM PATIENT INFORMATION. Last Name: First Name: Middle Initial: Social Security no.
Tracy Blum Physical Therapy, Inc NEW PATIENT REGISTRATION FORM PATIENT INFORMATION Last Name: First Name: Middle Initial: Date of Birth: / / Age: Sex: M F Social Security #: / / Marital Status (circle
Carter Family Dentistry
Carter Family Dentistry General Dentistry Patient Information Patient Name: Date: Last First MI Occupation: Employer: Title/Pos. 1 Male 1 Female 1 Single 1 Married 1 Child 1 Other Spouse s Name Social
APPLETON PLASTIC SURGERY CENTER, S. C. (920)
APPLETON PLASTIC SURGERY CENTER, S. C. (920)738-7200 Please print legibly and fill in or correct all fields. Patient Name Parent/Legal Guardian Name Address Last First Middle Last First Middle Street &
COSMETIC HISTORY FORM
COSMETIC HISTORY FORM IF THIS IS YOUR FIRST VISIT WITH US, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone:
PATIENT INFORMATION. Last Name: First Name: Middle Initial: Address:
PATIENT INFORMATION Today s Date: Last Name: First Name: Middle Initial: Address: STREET CITY STATE ZIP CODE Gender: Male Female Social Security #: Date of Birth: Home Phone: Cell Phone Work Phone: E-mail:
CHIROPRACTIC HEALTH QUESTIONNAIRE
CHIROPRACTIC HEALTH QUESTIONNAIRE Name: SS#: Today s Date: / / Address: City: State: Zip: What you prefer to be called: Age: Birthdate: / / Handedness: Height: Weight: Number of Children: Male Female Marital
Policy Application Individual and Family
Policy Application Individual and Family Important note about filling in this form: The answers you give to the questions contained in this Application will form the basis of any insurance policy issued,
Acknowledgement of Receipt of Privacy Notice Documentation of Attempt to Obtain Written Acknowledgment
Acknowledgement of Receipt of Privacy Notice Documentation of Attempt to Obtain Written Acknowledgment As required by the Health Insurance Portability and Accountability Act of 1996, we document compliance
Patients who are running 20 minutes late for his/her scheduled appointment will be rescheduled to the next available appointment/ day.
Orthotics/ Durable Medical Equipment Policy H2T is NEVER able to guarantee payment by medical insurance carriers for Orthotics and/or Durable Medical Equipment. H2T will bill your medical insurance as
Patient Last Name: First MI. Responsible Party (if a minor) Address: (Street or PO Box) (City) (State) (Zip) Home Phone: Cell Phone: Work Phone:
Patient Last Name: First MI Responsible Party (if a minor) Address: (Street or PO Box) (City) (State) (Zip) Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security No.: Sex: Marital Status:
Complete information on all pages in ink. Sign and date last page.
EMPLOYEE SELF-FUNDED HEALTH PLAN ENROLLMENT CARD SECTION 1 EMPLOYEE INFORMATION FULL NAME OF EMPLOYEE MARITAL STATUS RESIDENCE ADDRESS CITY STATE ZIP CASE NO. TELEPHONE NUMBER (include area code) Best
PATIENT REGISTRATION
PATIENT REGISTRATION Last / First / M.I. Patient Information Address / APT# City / State / Zip Phone # SSN: DOB Male Female Marital Status: Occupation Patient Email Address Assignment and Release I hereby
Allianz EFU Health Insurance Limited -Window Takaful Operations
Allianz EFU Health Insurance Limited -Window Takaful Operations A Health Takaful Product For Families APPLICATION FORM Allianz EFU Health Insurance Limited-Window Takaful Operations Pakistan s First Specialized