Dd 2807 2 Form PDF Details

Dd 2807 2 form is used to request an exception to the Department of DefenseINSTrucion 6055.19, "The preparation, processing, and handling of personnel records." This form can be used to request an exception to the retention or destruction schedule for military records. It can also be used to request an extension of time for submitting a records disposition authority. This form must be submitted by the unit commander or designee. The requester must include a justification for the requested exception. The DD 2807 2 form is available on the Defense Manpower Data Center website. For more information on dd 2807 2 forms or other military recordkeeping topics, please contact the DMDC Military Personnel Records Ask A Question site.

QuestionAnswer
Form NameDd 2807 2 Form
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesdd 2807 2, 2807 2 fillable, dd form 2807 2, dd 2807 2 2019

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INSTRUCTIONS FOR DD FORM 2807-2,

MEDICAL PRESCREEN OF MEDICAL HISTORY REPORT

1.This form is to be completed by each individual who requires medical processing in accordance with Army Regulation 40-501 Chapter 2 standards, or Department of Defense Directive 6130.3, "Physical Standards for Appointment, enlistment, or Induction." The form should be completed by the applicant with the assistance of the recruiter, parent(s), or guardian, as needed (see page 2).

2.Use of this form will also facilitate efficient, timely, and accurate medical processing of individuals applying for service in the

United States Armed Forces or Coast Guard. The form is designed to assist recruiters in the medical pre-screening of applicants.

3.The individual completing the DD Form 2807-2 will submit the form, at a minimum, 1 processing day in advance to the MEPS projected to process the individual. A minimum of 2 processing days in advance is required if support documentation (e.g., private physicians paperwork, treatment records, etc.) is required to augment the MEPS CMO review.

EXPLANATION OF CODES.

Items are followed by numbers that refer to the following:

(1)If the applicant has been seen by a physician and/or has been hospitalized for the condition, obtain medical documentation with a medical release form and submit records to the MEPS Medical Section. After the MEPS Medical Officer reviews the provided information, the appropriate recruiting service member will be informed of the examinee's processing status, or if additional record review or specialty consultation may be required for further processing or qualification determination.

a.If the applicant was evaluated and/or treated on an out-patient basis, obtain a copy of actual treatment records of the private medical doctor (PMD) or health care provider (HCP), to include (if any):

-office or clinic assessment and progress notes, including the initial assessment documents, subsequent evaluation and treatment documents, and record and date when released from doctor's care to full, unrestricted activity;

-emergency room (ER) report;

-study reports (e.g., x-ray report(s), magnetic resonance imaging (MRI) report(s), or Computerized Tomography (CT) scan report(s), etc.);

-procedure reports (e.g., arthroscopy, electroencephalogram (EEG; brain wave test), echocardiogram (ultrasound of the heart), etc.);

-pathology reports (e.g., if tissue specimens taken from the body and sent to lab for microscopic diagnosis, etc.);

-specialty consultation records (e.g., neurologist, cardiologist, OB/Gynecologist, gastroenterologist, orthopedic surgeon, pulmonologist, allergist, etc.).

b.If the applicant was hospitalized, then obtain a copy of the hospital record, to include (if any): ER report, admission history and physical, study reports, procedure reports, operative report (especially necessary for surgery to bone or joint), pathology report, specialty consultation reports, and discharge summary.

(2)If an applicant has been diagnosed or treated since age 12 for any attention disorder (Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD), etc.), academic skills or perceptual defect, or has had an Individual Education Plan (IEP), call the MEPS for additional instructions.

(3)Condition to be discussed with the examining Medical Officer at time of the medical examination.

(4)Call MEPS Medical Section to discuss examinee's medical history BEFORE sending the individual in for physical examination.

(5)Send medical reports to MEPS for review before sending applicant for physical ("papers only" medical review), and MEPS Medical Section will advise regarding further medical processing. Records pertaining to non-psychiatric diagnoses may be sent to the Medical Section of the processing MEPS, with the envelope stating: "CONFIDENTIAL: MEPS MEDICAL SECTION."

(6)Send all documentation relating to ANY past or present evaluation, treatment or consultation with a psychiatrist, psychologist, counselor or therapist, on an inpatient or out-patient basis for any reason, including but not limited to counseling or treatment for adjustment or mood disorder, family or marriage problem, depression, treatment or rehabilitation for alcohol, drug or other substance abuse, directly from the treating clinician and/or hospital to the MEPS Chief Medical Officer. The envelope must bear the following statement: "CONFIDENTIAL: FOR EYES OF THE MEDICAL OFFICER ONLY."

(7)May require an orthopedic consult, scheduling to be coordinated by the MEPS CMO and Medical Section.

DD FORM 2807-2, AUG 2011

Page 1 of 6 Pages

MEDICAL PRESCREEN OF MEDICAL HISTORY REPORT

OMB No. 0704-0413

OMB approval expireS

(Chapter #2 Physicals Only)

AUG 31, 2014

The public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 1155 Defense Pentagon, Washington, DC 20301-1155 (0704-0413). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM AS INDICATED ON PAGE 2.

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 136, DoD Instruction 6130.03, and E.O. 9397 (SSN).

PRINCIPAL PURPOSE(S): The primary collection of this information is from individuals seeking to join the Armed Services. The information collected on this form is used to obtain medical data for a determination of medical fitness for enlistment, induction and applintment of individuals to the Armed Forces.

ROUTINE USE(S): The DoD Blanket Routine Uses found at http://privacy.defense.gov/blanket_uses.shtml apply to this collection.

DISCLOSURE: Voluntary. However, failure by an applicant to provide the information may result in delay or possible rejection of the individual's application to enter the Armed Forces. An applicant's SSN is used during the recruitment process to keep all records together and when requesting civilian medical records.

WARNING: The information you have given constitutes an official statement. Federal law provides severe penalties (up to 5 years confinement or a $10,000 fine or both), to anyone making a false statement. If you are selected for enlistment, commission, or entrance into a commissioning program based on a false statement, you can be tried by military courts-martial or meet an administrative board for discharge and could receive a less than honorable discharge that would affect your future.

1. APPLICANT

a. LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)

 

 

 

 

b. DATE OF BIRTH (YYYYMMDD)

c. SOCIAL SECURITY NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d. HEIGHT

e. WEIGHT

f. MAXIMUM WEIGHT

 

g. SERVICE/COMPONENT

 

 

 

Regular

h. DATE SCREENED

 

 

 

 

 

Army

 

Marine Corps

 

Coast Guard

 

Reserve

(YYYYMMDD)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

lbs.

 

 

 

Navy

 

Air Force

 

 

 

National Guard

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. Mark each item "YES" or "NO". Every item marked "YES" must be fully explained in Item 2b.

a. HAVE YOU EVER HAD OR DO YOU NOW HAVE:

YES

NO

 

 

YES

NO

 

 

 

 

 

 

 

 

(1)

Asthma, wheezing, or inhaler use (4)

 

 

(24)

Any other heart problems (4)

 

 

 

 

 

 

 

 

 

 

(2)

Dislocated joint, including knee, hip, shoulder, elbow, ankle

 

 

(25)

High blood pressure (4)

 

 

 

or other joint (1)(7)

 

 

(26)

Discharged from military service for medical reasons (4)

 

 

 

 

 

 

 

 

 

 

(3)

Epilepsy, fits, seizures, or convulsions (4)

 

 

(27)

Ulcer (stomach, duodenum or other part of intestine) (4)

 

 

 

 

 

 

 

 

 

 

(4)

Sleepwalking (4)

 

 

(28)

Received disability compensation for an injury or other medical

 

 

(5)

Recurrent neck or back pain (4)(1)(7)

 

 

 

condition (4)

 

 

 

 

 

 

 

 

 

 

(6)

Rheumatic fever (4)

 

 

(29)

Hepatitis (liver infection or inflammation) (4)

 

 

 

 

 

 

 

 

 

 

(7)

Foot pain (3)

 

 

(30)

Intestinal obstruction (locked bowels), or any other chronic or

 

 

 

 

 

 

 

recurrent intestinal problem, including small intestine or colon

 

 

 

 

 

 

 

(8)

A swollen, painful, or dislocated joint or fluid in a joint

 

 

 

problems, such as Crohn's disease or colitis (4)

 

 

 

(knee, shoulder, wrist, elbow, etc.) (1)(7)

 

 

(31)

Detached retina or surgery for a detached retina (4)

 

 

 

 

 

 

 

 

 

 

(9)

Double vision (4)

 

 

(32)

Surgery to remove a portion of the intestine (other than the

 

 

(10)

Periods of unconsciousness (4)

 

 

 

appendix) (4)

 

 

 

 

 

 

 

 

 

 

(11)

Frequent or severe headaches causing loss of time from

 

 

(33)

Any other eye condition, injury or surgery (4)

 

 

 

work or school or taking medication to prevent frequent or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

severe headaches (4)

 

 

(34)

Are you over 40? (If so, call the MEPS for information on

 

 

(12)

Wear contact lenses (If so, bring your contact lens

 

 

 

special requirements for over-40 physicals) (4)

 

 

 

 

 

 

 

 

 

kit and solution so you can remove your contact when we

 

 

(35)

Gall bladder trouble or gall stones (4)

 

 

 

test your vision at the MEPS; also, if you have a pair of

 

 

 

 

 

 

 

 

 

 

 

 

eyeglasses, bring them with you no matter how old they are.)

 

 

(36)

Jaundice (4)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(13)

Fainting spells or passing out (4)

 

 

(37)

Missing a kidney (4)

 

 

 

 

 

 

 

 

 

 

(14)

Head injury, including skull fracture, resulting in concussion,

 

 

(38)

Allergy to common food (milk, bread, eggs, meat, fish or

 

 

 

loss of consciousness, headaches, etc. (4)

 

 

 

other common food) (4)

 

 

 

 

 

 

 

 

 

 

(15)

Back surgery (4)

 

 

(39)

(Females only) Abnormal PAP smear or gynecological problem (4)

 

 

 

 

 

 

 

 

 

 

(16)

Seen a psychiatrist, psychologist, social worker, counselor or

 

 

(40)

(Males only) Missing a testicle, testicular implant, or

 

 

 

other professional for any reason (inpatient or outpatient)

 

 

 

 

 

 

 

 

 

 

 

 

including counseling or treatment for school, adjustment,

 

 

 

undescended testicle (4)

 

 

 

family, marriage or any other problem, to include depression,

 

 

 

 

 

 

 

or treatment for alcohol, drug or substance abuse (6)(2)

 

 

(41)

Broken bone requiring surgery to repair (with or without pins,

 

 

 

 

 

 

 

 

(17)

Any of the following skin diseases:

 

 

plates, screws or other metal fixation devices used in repair) (1)(7)

 

 

 

(a) Eczema (5)

 

 

(42)

Ruptured or bulging disk in your back or surgery

 

 

 

(b) Psoriasis (5)

 

 

 

for a ruptured or bulging disk (4)

 

 

 

 

 

 

 

 

 

 

 

(c) Atopic dermatitis (5)

 

 

(43)

Thyroid condition or take medication for your thyroid (4)

 

 

 

 

 

 

 

 

 

 

(18)

Irregular heartbeat, including abnormally rapid or slow

 

 

(44)

Limitation of motion of any joint, including knee, shoulder,

 

 

 

heart rates (4)

 

 

 

wrist, elbow, hip or other joint (4)(1)(7)

 

 

 

 

 

 

 

 

 

 

(19)

Allergic to bee, wasp, or other insect stings

 

 

(45)

Drug or alcohol rehab (4)

 

 

 

(itching/swelling all over and/or get short of breath) (4)

 

 

(46)

Kidney, urinary tract or bladder problems, surgery, stones or

 

 

 

 

 

 

 

 

(20)

Heart murmur, valve problem or mitral valve prolapse (4)

 

 

 

other urinary tract problems (4)

 

 

 

 

 

 

 

 

 

 

(21)

Allergic to wool (4)

 

 

(47)

Sugar, protein or blood in urine (4)

 

 

 

 

 

 

 

 

 

 

(22)

Heart surgery (4)

 

 

(48)

Surgery on a bone or joint (knee, shoulder, elbow, wrist, etc.)

 

 

(23)

Been rejected for military service (temporary

 

 

 

including Arthroscopy with normal findings (1)(7)

 

 

 

 

 

 

 

 

 

or permanent) for medical or other reasons (4)

 

 

(49)

Taking any medications (If so, list reason in Item 2b.)

 

 

 

 

 

 

 

 

 

 

DD FORM 2807-2, AUG 2011

PREVIOUS EDITION IS OBSOLETE.

Page 2 of 6 Pages

MEDICAL PRESCREEN

LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)

 

 

 

 

 

 

 

SOCIAL SECURITY NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2a. (Continued) HAVE YOU EVER HAD OR DO YOU NOW HAVE:

YES

NO

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(50)

Pain or swelling at the site of an old fracture (4)(1)(7)

 

 

(64)

Shoulder, knee, or elbow problem (out of place) (4)(1)(7)

 

 

 

 

 

 

 

 

 

 

 

(51)

Perforated ear drum or tubes in ear drum(s) (4)

 

 

(65)

Locking of the knee or other joint (4)(1)(7)

 

 

 

 

 

 

 

 

 

 

 

 

(52)

Anemia (4)

 

 

(66)

Giving way of knee or other joint (4)(1)(7)

 

 

 

 

 

 

 

 

 

 

 

 

(53)

Ear surgery, to include mastoidectomy or repair of perforated

 

 

(67)

Cataracts or surgery for cataracts (4)

 

 

 

 

ear drum, hearing loss or need/use a hearing aid (4)

 

 

(68)

Eye surgery, including radial keratotomy, lens implant or

 

 

 

 

 

 

 

 

(54)

Night blindness (4)

 

 

 

other eye surgery to improve your vision (4)

 

 

 

 

 

 

 

 

 

 

 

 

(55)

Arthritis (4)

 

 

(69)

Collapsed lung or other lung condition (4)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(56)

Absence or disturbance of the sense of smell (4)

 

 

(70)

Bed wetting since age 12 (4)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(57)

Absence or removal of the spleen, or rupture or tear of the

 

 

(71)

Evaluation, treatment, or hospitalization for alcohol abuse,

 

 

 

spleen without removal (4)

 

 

dependence, or addiction (4)(6)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(58)

Anorexia or other eating disorder (4)

 

 

(72)

Taken medication, drugs, or any substance to improve

 

 

 

(59)

Cracked bone or fracture(s) (4)

 

 

 

attention, behavior, or physical performance (2)(1)(6)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(60)

Bursitis (4)

 

 

(73)

Do you smoke?

(If yes:)

 

 

 

 

 

 

 

 

 

 

 

 

(a) Type

 

 

 

 

 

 

 

 

 

 

(61)

Braces (If you wear or are planning on obtaining braces for

 

 

 

 

 

Cigarettes

 

Cigars

 

 

Smokeless tobacco

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

your teeth, have the orthodontist submit a letter stating

 

 

 

(b) How many per day?

(c) Date last used

 

 

 

 

that braces will be removed before active duty date;

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

release form and sample format can be found in the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Recruiter's Medical Guide.)

 

 

(74) Evaluation, treatment, or hospitalization for substance use,

 

 

 

 

 

 

 

 

(62)

Loss of finger, toe or part thereof (4)

 

 

 

abuse, addiction or dependence (including illegal drugs,

 

 

 

 

 

 

 

 

prescription medications, or other substances)

 

 

 

(63)

Loss of the ability to fully flex (bend) or fully extend a finger,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

toe or other joint (4)(1)(7)

 

 

(75)

Any illnesses, surgery, or hospitalization not listed above

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b.EXPLAIN ALL "YES" ANSWERS TO QUESTIONS (1) - (75) ABOVE. (Describe answer(s), give date(s) of problems, name doctor(s), clinic(s), hospital(s), treatment given and current medical status. Attach additional sheet(s) if necessary.)

DD FORM 2807-2, AUG 2011

Page 3 of 6 Pages

MEDICAL PRESCREEN

LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)

SOCIAL SECURITY NUMBER

b. EXPLAIN ALL "YES" ANSWERS TO QUESTIONS (1) - (74) ABOVE. (Continued)

3. CURRENT PRIMARY CARE PHYSICIAN(S)/PRACTITIONER(S) AND/OR CLINIC(S) (Attach additional sheets if necessary)

a. NAME(S)

b.ADDRESS (Include ZIP Code)

c.TELEPHONE (Include Area Code)

4. PREVIOUS PRIMARY CARE PHYSICIAN(S)

a. NAME(S)

b.ADDRESS (Include ZIP Code)

c.TELEPHONE (Include Area Code)

5. CURRENT INSURANCE PROVIDER

a. NAME

b.ADDRESS (Include ZIP Code)

c. INSURANCE ID NUMBER

6. PREVIOUS INSURANCE PROVIDER(S)

a. NAME(S)

b. ADDRESS (Include ZIP Code)

c. INSURANCE ID NUMBER

STOP AND READ: THE FOLLOWING STATEMENTS APPLY TO SIGNATURES AT ITEMS 7 AND 8

I certify the information on this form is true and complete to the best of my knowledge and belief, and no person has advised me to conceal or falsify any information about my physical and mental history.

I further understand that I may be requested to provide medical documentation regarding issues within my medical history.

I authorize any of the doctors, hospitals, clinics or insurance company(ies) to furnish the Department of Defense medical authority a complete transcript of my medical record for purposes of processing my application for military service.

7. APPLICANT

a. SIGNATURE

b.DATE SIGNED (YYYYMMDD)

8. PARENT OR GUARDIAN SIGNATURE FOR MINOR (Mandatory) OR PARENT ASSISTING TO COMPLETE FORM (Voluntary)

a.NAME (Last, First, Middle Initial)

b. SIGNATURE

c.DATE SIGNED (YYYYMMDD)

9.RECRUITING REPRESENTATIVE: I certify all information is complete and true to the best of my knowledge. I have conducted the medical prescreening requirements as directed by service regulations.

a.NAME (If representative was used) (Last, First, Middle Initial)

b. PAY GRADE

c. SIGNATURE

d.DATE SIGNED (YYYYMMDD)

DD FORM 2807-2, AUG 2011

Page 4 of 6 Pages

MEDICAL PRESCREEN

LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)

SOCIAL SECURITY NUMBER

10.PHYSICIAN'S SUMMARY AND ELABORATION OF ALL PERTINENT DATA (Physician shall comment on all positive answers in questions (1) - (74). Physician may develop by interview any additional medical history deemed important, and record any significant findings here.)

a. COMMENTS

11. MEDICAL OFFICER'S PRESCREENING COMMENTS: Based on information provided, further processing is:

a.ON PRESCREEN:

(1)AUTHORIZED

(2)NOT JUSTIFIED (Permanent Disqualification (PDQ)):

(a) Profile SerialICD

(b) Process for Waiver (CMO initials)

(3)DEFERRED (See Comments above):

(a)Pending review of additional documentation

(b) RJ Date (If applicable)

 

(CMO initials)

 

 

 

b. ON EXAM:

 

 

 

 

 

 

 

(1) APPROVED

 

(2) DEFERRED:/

 

(a) Additional information needed (See DD Form 2808)

 

 

 

 

 

 

(3) NOT JUSTIFIED:

 

(b) Information different than on prescreen

 

 

 

 

 

 

 

 

 

 

 

 

(c) Form not prescreened by MEPS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e. DATE SIGNED

c. TYPED OR PRINTED NAME OF EXAMINER

d. SIGNATURE

 

 

 

 

 

 

 

(YYYYMMDD)

 

 

 

 

 

 

 

 

(4) MEPS USE:

 

 

(a) AE

 

(c) PRI

 

 

 

(b) RE

 

(d) N/A

 

 

 

 

 

 

12.NUMBER OF ATTACHED SHEETS

DD FORM 2807-2, AUG 2011

Page 5 of 6 Pages

MEDICAL PRESCREEN

LAST NAME - FIRST NAME - MIDDLE INITIAL (SUFFIX)

SOCIAL SECURITY NUMBER

13.COMMENTS (Continued)

DD FORM 2807-2, AUG 2011

Page 6 of 6 Pages

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1. While filling in the form 2807 2, be certain to include all of the important blanks in its associated section. It will help speed up the work, enabling your information to be handled fast and properly.

Find out how to fill in 2807 2 fillable part 1

2. The next stage is to fill in all of the following blanks: Back surgery, Females only Abnormal PAP smear, Seen a psychiatrist psychologist, Any of the following skin diseases, a Eczema, b Psoriasis, c Atopic dermatitis, Males only Missing a testicle, Broken bone requiring surgery to, Ruptured or bulging disk in your, Thyroid condition or take, Irregular heartbeat including, Limitation of motion of any joint, Allergic to bee wasp or other, and Heart murmur valve problem or.

Filling in section 2 in 2807 2 fillable

3. Through this step, check out LAST NAME FIRST NAME MIDDLE, SOCIAL SECURITY NUMBER, MEDICAL PRESCREEN, a Continued HAVE YOU EVER HAD OR, YES NO, YES NO, Pain or swelling at the site of, Shoulder knee or elbow problem, Perforated ear drum or tubes in, Locking of the knee or other, Anemia, Ear surgery to include, Night blindness, Arthritis, and Giving way of knee or other joint. These are required to be taken care of with highest awareness of detail.

Guidelines on how to fill in 2807 2 fillable part 3

As to YES NO and MEDICAL PRESCREEN, be certain you review things in this current part. These two could be the key ones in the PDF.

4. The next part arrives with the next few empty form fields to fill out: LAST NAME FIRST NAME MIDDLE, SOCIAL SECURITY NUMBER, MEDICAL PRESCREEN, b EXPLAIN ALL YES ANSWERS TO, CURRENT PRIMARY CARE, a NAMES, b ADDRESS Include ZIP Code, c TELEPHONE Include Area, Code, PREVIOUS PRIMARY CARE PHYSICIANS, a NAMES, b ADDRESS Include ZIP Code, c TELEPHONE Include Area, and Code.

SOCIAL SECURITY NUMBER, c TELEPHONE Include Area, and PREVIOUS PRIMARY CARE PHYSICIANS in 2807 2 fillable

5. To wrap up your document, this particular area involves a couple of extra fields. Completing CURRENT INSURANCE PROVIDER, a NAME, b ADDRESS Include ZIP Code, c INSURANCE ID NUMBER, PREVIOUS INSURANCE PROVIDERS, a NAMES, b ADDRESS Include ZIP Code, c INSURANCE ID NUMBER, STOP AND READ THE FOLLOWING, I certify the information on this, I further understand that I may be, I authorize any of the doctors, APPLICANT, a SIGNATURE, and b DATE SIGNED is going to conclude the process and you're going to be done before you know it!

c INSURANCE ID NUMBER, b ADDRESS Include ZIP Code, and I authorize any of the doctors in 2807 2 fillable

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