Standard Health Application PDF Details

There's a new application in town and it's shaking up the healthcare industry. Welcome to the Standard Health Application Form (SHAF), the latest and greatest way to apply for health insurance. Whether you're self-employed or work for a company that doesn't offer benefits, ShAF is perfect for you! With its simple online interface, you can apply for coverage in minutes. Plus, there are no hidden fees - what you see is what you get! So why wait? Get started today and join the thousands of Americans who have already made the switch to ShAF.

This information will aid you to understand better the details of the standard health application before you begin filling it out.

QuestionAnswer
Form NameStandard Health Application
Form Length10 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 30 sec
Other namesillinois standard application provider, illinois standard health, illinois standard health for small employers, illinois depart of public health application

Form Preview Example

Blue Cross and Blue Shield of Illinois Cover Page to the

Illinois Standard Health Employee Application for Small Employers

(Groups sized 2 - 150)

The purpose of this document is to help you – an employee requesting coverage from Blue Cross and Blue Shield of Illinois (BCBSIL) – fill out the new standard enrollment application created by the State of Illinois Department of Insurance.

As a result of the Illinois Insurance Fairness Act (Public Act 96-0857), the Illinois Department of Insurance created standard enrollment applications that must be used by all insurance companies doing business in the small group and individual markets.

The attached standard application goes into effect January 1, 2011 and replaces the small group enrollment applications previously used by insurance companies.

Although all insurance companies must use this standard enrollment application, the business needs and practices of all insurance companies are not the same. Not all the information requested on the new standard enrollment application is required by BCBSIL. However, there is information BCBSIL needs for the enrollment process that is not on the standard enrollment application.

The information below will help you understand how to complete each section of the standard enrollment application for enrollment with BCBSIL.

1.Employer Information

Your employer can use the Illinois Standard Health Employee Application with one or more insurance companies to request quotes for employee health insurance. This standard enrollment application means you do not need to fill out different applications from each insurance company. For your benefit, space is provided on the standard enrollment application so your employer can list the different insurance companies that will receive your health information.

You will see references to "spouse/domestic partner" and "retiree" in the standard enrollment application. Domestic partners and retirees are eligible only if your employer chooses to cover them. Check with your employer if you are not sure.

2.Section B – Coverage Requested

Choose the type of health coverage/product you want based on the option(s) your employer has offered you.

Some employers may offer only one type of coverage such as a PPO health benefit plan.

Others may provide different options such as a PPO, an HMO, and/or a plan that includes a Health Savings Account (HSA) and/or a Health Care Account (HCA).

You and your dependents (spouse/domestic partner and children) will all be enrolled in the same product. You cannot pick different products for each person.

BCBSIL offers the following products for small group business. If you are not sure which product(s) are available to you, please ask your employer.

PPO

HMO

HSA

HCA

 

• BlueAdvantageSM

• BlueAdvantageSM HMO

• BlueEdgeSM

HSA

• BlueEdgeSM Direct HCA

 

Entrepreneur PPO

• HMO Value Choice

• BlueEdgeSM

Select HSA

 

 

• BluePrint PPO

 

 

 

 

 

 

 

• BlueChoice Select®

 

 

 

 

 

• BlueChoice Select®

 

 

 

 

 

Value Choice

 

 

 

 

 

• PPO Value Choice

 

 

 

 

 

• CPO

 

 

 

 

 

• CPO Value Choice

 

 

 

 

 

 

 

 

 

 

22997.1211

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

Page 1

3.Section C – Waiver of Coverage

You may enroll yourself and your dependents (spouse/domestic partner and children) in any coverage that your employer makes available to you, and that BCBSIL offers. While the standard enrollment application may appear to suggest that you can waive enrolling yourself for coverage but still enroll your dependents, BCBSIL’s policy requires that you (the employee) enroll in order to also enroll your dependents. If you choose to waive any coverage, your dependents cannot enroll in that coverage. However, you can enroll yourself in a coverage and choose to waive it for any of your dependents.

Please use this section to indicate if you do not wish to enroll yourself and/or any of your dependents in the following types of coverage:

• Medical

• Dental

• Basic Life

• Dependent Life

Short-Term Disability (BCBSIL offers only to employees)

• Voluntary Life (BCBSIL offers only to employees)

While you may see these types of coverage on the standard application, they are not available from BCBSIL for small group business:

Vision

Long-Term Disability

For small group business, BCBSIL does not consider “Individual Coverage” (the second option on the standard application) as a valid reason to decline your employer-offered coverage.

4.Section D – Individuals Requesting Coverage

Weight and Height - BCBSIL requires the weight and height for yourself and your spouse/domestic partner. BCBSIL also requests weight and height be provided for any dependent that is 18 or older.

Military Veteran Dependents - If you have dependents that are military veterans, you must include their honorable discharge documentation (Form DD-214).

Disabled Dependents - Medical certification must be provided for disabled dependents.

HMO Coverage - If you have elected to enroll in HMO coverage, information about your Primary Care Physician (PCP) is needed. The standard enrollment application provides space for your PCP and his or her identification number. However, BCBSIL requires more information about your physician. To accommodate this, a separate HMO / CPO Provider Selection Enrollment and Change Form is also required for HMO enrollees. This form is used to collect the following information:

Independent Practice Association (IPA) / Medical Group Number – this is required for BCBSIL to correctly identify the location you have chosen to access care from your PCP.

PCP name and the identification number.

Female enrollees may also choose a Woman’s Principal Health Care Provider (WPHCP), so there is space to list this provider’s name and identification number as well.

CPO Coverage - BCBSIL offers a Community Participating Option (CPO) health benefit plan. This is similar to a PPO health benefit plan, but the member can gain greater savings by using providers at specific hospitals in the CPO network. Therefore, if you have chosen the CPO product, please use the HMO / CPO Provider Selection Enrollment and Change Form to indicate the number of the CPO network you have selected.

5.Section E – Current / Prior Coverage Information: Medicare

For small group business,“Dual Enrollment” is not an applicable Medicare entitlement reason for BCBSIL.

6.Sections F & G – Health Statement / Additional Information

This section should be completed by employees of groups that have 2-50 enrolling employees. If you are not sure about completing this section, check with your employer.

For health coverage, BCBSIL does not require the health statement questions to be completed by employees of groups that have more than 50 employees enrolling.

For basic life coverage, the health statement questions must be completed by the employee if the group has two or more eligible employees AND is applying for an amount over the guarantee issue, applying for voluntary life coverage or for any late enrollment.

Two pages are left blank so that information in these sections can be pulled out for underwriting (if applicable).

7.Section H – Additional Coverage Options

As stated in item #3, the following types of coverage are not available from BCBSIL for small group business:

Vision

Long-Term Disability

22997.1211

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Illinois Standard Health Employee Application for Small Employers

INSURER USE ONLY

Policy/Group No.

Section No.

Effective Date

New Hire Waiting Period

For assistance in completing this application, please contact your employer or insurance agent. For information about your health insurance rights under state and federal law, and other resources, please contact the Illinois Department of Insurance’s Office of Consumer Health Insurance toll free at (877) 527-9431.

This standard application is intended to simplify your health insurance application process. You will only need to complete this one application, even when your employer has requested quotes from multiple insurance companies.

The information you provide in this application will be sent to the following insurance companies: (To be completed by employer)

Insurer: _______________________________ Insurer: _______________________________ Insurer: _______________________________

Insurer: _______________________________ Insurer: _______________________________ Insurer: _______________________________

TO BE COMPLETED BY EMPLOYER

Employer Name:

 

 

 

Phone #:

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

Reason for Enrollment (Mark all that apply)

 

 

 

 

 

 

New Enrollment:

New Group Open Enrollment

New Hire (Date: ____________________________) Late Enrollee

 

 

Special Enrollment:

Adoption Court Order Dependent Addition Divorce Domestic Partner

 

Loss of Coverage

Marriage

Newborn Other

Date of Event: _________/__________/__________

 

 

Employment Status:

Active Retiree (Retirement Date: ________/________/________)

 

Illinois Continuation

COBRA

 

 

 

 

Employee Dependent

 

 

 

 

Qualifying Event: ________________________________

 

 

Start Date ________/________/_________ Projected End Date ________/________/_________

A Employee Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name (Last)

 

 

(First)

 

 

 

(MI)

 

 

 

 

 

 

 

 

 

 

Job Title:

 

 

 

 

Hire Date:

 

 

Hrs/Week:

 

 

 

 

 

 

 

 

 

Marital Status: Married

Single

Divorced Widowed Domestic Partner

 

 

 

 

 

 

 

 

 

 

 

 

Home Address:

 

 

 

 

 

 

Apt #:

 

 

 

 

 

 

 

 

City:

 

 

 

 

State:

Zip:

 

 

 

 

 

 

 

 

 

 

Home (or Cell) Phone: (

)

 

 

 

Business Phone: (

)

 

 

 

 

 

 

 

 

 

 

 

 

 

Email Address (optional):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B Coverage Requested

Medical

Employee: Yes No

Spouse/Domestic Partner: Yes No

Child(ren): Yes No

Plan Choice:

Plan Choice:

Plan Choice:

 

 

 

If you are waiving (declining) coverage for yourself or any member of your family, you must complete Section C below.

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ILLINOIS STANDARD HEALTH APPLICATION – SMALL EMPLOYER

Employer Name ________________________________ Employee Name __________________________________________

CWaiver of Coverage

Please complete this section only if you are waiving (declining) coverage for yourself or one or more of your family members.

I acknowledge that I have been given the opportunity to apply for group coverage available to me and my dependents through my employer.

I understand and agree:

If I am declining coverage for myself, my spouse/domestic partner, or my dependent child(ren) because of other coverage, I may in the future be able to enroll myself, my spouse/domestic partner, or my dependent child(ren) provided that I request enrollment within 31 days after the other coverage ends.

If I have a new spouse/domestic partner or child as a result of marriage, birth, adoption, or placement for adoption, I may be able to enroll myself and my new spouse/domestic partner or child provided that I request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.

If I decide to request coverage in the future, for a reason other than the termination of other coverage or the addition of a new spouse/domestic partner or child, I may be considered a late enrollee, if applicable, or I may have to wait until the plan’s next open enrollment period. I also understand that as a late enrollee, coverage for preexisting conditions may be excluded for up to a period of 18 months. This period may be offset by the time I, my spouse/domestic partner, or my dependent child(ren) was covered under a qualified health plan.

I certify that I was not pressured, forced, or unfairly induced by my employer, the agent, or the insurer(s) into waiving or declining the group coverage.

I DO NOT want, and hereby waive, coverage for (initial next to all that apply):

Medical for

[

] Myself

[

] My Spouse/Domestic Partner

[

] My Dependent Child(ren)

 

 

 

 

 

 

 

Dentalfor

[

] Myself

[

] My Spouse/Domestic Partner

[

] My Dependent Child(ren)

 

 

 

 

 

 

 

Visionfor

[

] Myself

[

] My Spouse/Domestic Partner

[

] My Dependent Child(ren)

 

 

 

 

 

 

 

Basic Lifefor

[

] Myself

[

] My Spouse/Domestic Partner

[

] My Dependent Child(ren)

 

 

 

 

 

 

 

Dependent Lifefor

[

] Myself

[

] My Spouse/Domestic Partner

[

] My Dependent Child(ren)

 

 

 

 

 

 

 

Voluntary Lifefor

[

] Myself

[

] My Spouse/Domestic Partner

[

] My Dependent Child(ren)

 

 

 

 

 

 

 

Short-Term Disabilityfor

[

] Myself

[

] My Spouse/Domestic Partner

[

] My Dependent Child(ren)

 

 

 

 

 

 

 

Long-Term Disabilityfor

[

] Myself

[

] My Spouse/Domestic Partner

[

] My Dependent Child(ren)

If offered.

I am declining group coverage for the following reason(s): (check all that apply)

Spouse/Domestic Partner’s Employer Plan

Individual Coverage (Non-Group Plan)

COBRA/State Continuation

Medicare or other Government Program

Other (please explain): _________________________________________________________

If you are declining ALL coverage for ALL persons, please skip to the Acknowledgement & Signature section on page 10 of this application.

 

2

23071.0111

70670

ILLINOIS STANDARD HEALTH APPLICATION – SMALL EMPLOYER

Employer Name ________________________________ Employee Name __________________________________________

DIndividuals Requesting Coverage

List yourself and all eligible family members to be included under coverage.

Please check with your employer or insurance agent about who may qualify as an eligible family member under the policy.

Illinois’ Young Adult Dependent Coverage law allows parents to cover children up to the age of 26, and up to age 30 for military veteran dependents, regardless of whether the child may be considered a dependent for tax or other purposes. For more information, please visit the Illinois Department of Insurance website at www.insurance.illinois.gov.

Note: For purposes of this application, an “eligible military veteran” is a veteran who served in the active or reserve components of the U.S. Armed Forces, including the National Guard, and who received a release or discharge other than a dishonorable discharge.

If additional space is required, please attach a separate sheet and be sure to sign and date that sheet.

Employee Name (Last) _______________________________ (First) _______________________________ (MI) _______

Social Security Number:

 

 

 

 

 

Date of Birth:

/

/

 

 

 

 

 

 

 

 

 

Weight:

lbs.

Height:

ft.

in.

 

Gender: Male

Female

 

 

 

 

 

 

 

 

HMO only (if/when applicable): Primary Care Physician:

 

 

 

Physician ID:

 

Spouse/Domestic Partner Name (Last) ________________________ (First) ________________________ (MI) ______

Social Security Number:

 

 

 

 

 

 

Date of Birth:

/

/

 

 

 

 

 

 

 

 

 

 

 

Weight:

lbs.

 

Height:

ft.

in.

 

Gender:

Male

Female

 

 

 

 

 

 

 

 

 

HMO only (if/when applicable): Primary Care Physician:

 

 

 

 

Physician ID:

 

 

 

Dependent Name (Last) _______________________________

(First) _______________________________ (MI) _______

Social Security Number:

 

 

 

 

 

 

Date of Birth:

/

/

 

 

 

 

 

 

 

 

 

 

 

Weight:

lbs.

 

Height:

ft.

in.

 

Gender:

Male

Female

 

 

 

 

 

 

 

 

 

 

 

Eligible Military Veteran: Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HMO only (if/when applicable): Primary Care Physician:

 

 

 

 

Physician ID:

 

 

 

Dependent Name (Last) _______________________________

(First) _______________________________ (MI) _______

Social Security Number:

 

 

 

 

 

 

Date of Birth:

/

/

 

 

 

 

 

 

 

 

 

 

 

Weight:

lbs.

 

Height:

ft.

in.

 

Gender:

Male

Female

 

 

 

 

 

 

 

 

 

 

 

Eligible Military Veteran: Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HMO only (if/when applicable): Primary Care Physician:

 

 

 

 

Physician ID:

 

 

 

Dependent Name (Last) _______________________________

(First) _______________________________ (MI) _______

Social Security Number:

 

 

 

 

 

 

Date of Birth:

/

/

 

 

 

 

 

 

 

 

 

 

 

Weight:

lbs.

 

Height:

ft.

in.

 

Gender:

Male

Female

 

 

 

 

 

 

 

 

 

 

 

Eligible Military Veteran: Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HMO only (if/when applicable): Primary Care Physician:

 

 

 

 

Physician ID:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

 

 

 

 

 

23071.0111

 

 

 

 

 

 

 

 

 

70670

ILLINOIS STANDARD HEALTH APPLICATION – SMALL EMPLOYER

Employer Name ________________________________ Employee Name __________________________________________

Dependent Name (Last) _______________________________

(First) _______________________________ (MI) _______

Social Security Number:

 

 

 

 

 

 

Date of Birth:

/

/

 

 

 

 

 

 

 

 

 

 

Weight:

lbs.

 

Height:

ft.

in.

 

Gender: Male

Female

 

 

 

 

 

 

 

 

 

 

Eligible Military Veteran: Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

HMO only (if/when applicable): Primary Care Physician:

 

 

 

Physician ID:

 

 

 

 

 

 

 

 

 

 

 

ECurrent/Prior Coverage Information

Please indicate for EACH person listed on this application any health coverage, including Medicare or Medicaid, in effect within 24 months prior to the proposed effective date of this coverage. Each person applying for coverage must be listed below. If no health care coverage was in effect within the past 24 months, please indicate NONE. If coverage is provided for a dependent from a previous marriage or relationship, please attach a copy of the court documentation showing who is responsible for the dependent(s)’ health care coverage so that the insurer can determine whose coverage is primary.

Note: If you have had health care coverage within the last 63 days, your Pre-Existing Condition (PEC) waiting period limitation may be partially or completely waived. To determine if this applies to you, you must provide proof of prior coverage, such as a Certificate of Creditable Coverage from your previous insurer. Submission of prior coverage information does not automatically waive any PEC limitation. You will be subject to an automatic PEC Waiting Period of up to 12 months until the insurer receives evidence of prior coverage.

If additional space is required, please attach a separate sheet and be sure to sign and date that sheet.

Employee Name (Last) _______________________________ (First) _______________________________ (MI) _______

Current/Most Recent Coverage: Group Medical Dental Individual Medical None

Dates of Coverage: From: _________/_________/_________ To: _________/_________/_________

Policyholder Name: ___________________________________ Insurer Name: __________________________________

Will the individual continue this coverage? Yes No

Prior Coverage (if any): Group Medical Dental Individual Medical None

Dates of Coverage: From: _________/_________/_________ To: _________/_________/_________

Policyholder Name: ___________________________________ Insurer Name: __________________________________

Spouse/Domestic Partner Name (Last) ________________________ (First) ________________________ (MI) ______

Current/Most Recent Coverage: Group Medical Dental Individual Medical None

Dates of Coverage: From: _________/_________/_________ To: _________/_________/_________

Policyholder Name: ___________________________________ Insurer Name: __________________________________

Will the individual continue this coverage? Yes No

Prior Coverage (if any): Group Medical Dental Individual Medical None

Dates of Coverage: From: _________/_________/_________ To: _________/_________/_________

Policyholder Name: ___________________________________ Insurer Name: __________________________________

Dependent Name (Last) _______________________________ (First) _______________________________ (MI) _______

Current/Most Recent Coverage: Group Medical Dental Individual Medical None

Dates of Coverage: From: _________/_________/_________ To: _________/_________/_________

Policyholder Name: ___________________________________ Insurer Name: __________________________________

Will the individual continue this coverage? Yes No

Prior Coverage (if any): Group Medical Dental Individual Medical None

Dates of Coverage: From: _________/_________/_________ To: _________/_________/_________

Policyholder Name: ___________________________________ Insurer Name: __________________________________

 

4

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ILLINOIS STANDARD HEALTH APPLICATION – SMALL EMPLOYER

Employer Name ________________________________ Employee Name __________________________________________

Dependent Name (Last) _______________________________ (First) _______________________________ (MI) _______

Current/Most Recent Coverage: Group Medical Dental Individual Medical None

Dates of Coverage: From: _________/_________/_________ To: _________/_________/_________

Policyholder Name: ___________________________________ Insurer Name: __________________________________

Will the individual continue this coverage? Yes No

Prior Coverage (if any): Group Medical Dental Individual Medical None

Dates of Coverage: From: _________/_________/_________ To: _________/_________/_________

Policyholder Name: ___________________________________ Insurer Name: __________________________________

Dependent Name (Last) _______________________________ (First) _______________________________ (MI) _______

Current/Most Recent Coverage: Group Medical Dental Individual Medical None

Dates of Coverage: From: _________/_________/_________ To: _________/_________/_________

Policyholder Name: ___________________________________ Insurer Name: __________________________________

Will the individual continue this coverage? Yes No

Prior Coverage (if any): Group Medical Dental Individual Medical None

Dates of Coverage: From: _________/_________/_________ To: _________/_________/_________

Policyholder Name: ___________________________________ Insurer Name: __________________________________

Dependent Name (Last) _______________________________ (First) _______________________________ (MI) _______

Current/Most Recent Coverage: Group Medical Dental Individual Medical None

Dates of Coverage: From: _________/_________/_________ To: _________/_________/_________

Policyholder Name: ___________________________________ Insurer Name: __________________________________

Will the individual continue this coverage? Yes No

Prior Coverage (if any): Group Medical Dental Individual Medical None

Dates of Coverage: From: _________/_________/_________ To: _________/_________/_________

Policyholder Name: ___________________________________ Insurer Name: __________________________________

Medicare: If you or any family members listed on this application have Medicare coverage, please complete the following information.

Enrolling Individual Name (Last) ___________________________ (First) ___________________________ (MI) _______

Medicare Part A Part B Part D Effective Date: _________/_________/_________

Reason for Medicare Entitlement: Age Disability ERSD Dual Enrollment

Medicare Number (please include

alpha prefix):

Enrolling Individual Name (Last) ___________________________ (First) ___________________________ (MI) _______

Medicare Part A Part B Part D Effective Date: _________/_________/_________

Reason for Medicare Entitlement: Age Disability ERSD Dual Enrollment

Medicare Number (please include

alpha prefix):

 

5

23071.0111

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23071.0111

70670

ILLINOIS STANDARD HEALTH APPLICATION – SMALL EMPLOYER

Employer Name ________________________________ Employee Name __________________________________________

FHealth Statement

Instructions:

1.The information you provide in this application is confidential. You should discuss with your employer if you prefer to submit the completed health statement directly to the insurance company or insurance broker.

2.The health information you provide below will be used by the insurance company to determine the price to charge your group for the coverage applied for and whether a Pre-Existing Condition Waiting Period(s) will apply to your coverage. Coverage for pre-existing conditions cannot be limited or excluded for dependents under the age of 19.

3.Each medical question below applies to all persons requesting coverage.

4.Answer the questions below with either Yes or No. If you answer Yes to any question, you must provide additional information in Section G below.

5.Do not leave any question unmarked.

6.Neither your employer nor your insurance agent can waive these requirements or may authorize you to provide anything less than a complete and accurate response to each of the questions.

7.After you submit this application, the insurance company may call you to obtain additional confidential information needed to evaluate and aid the processing of your application.

1For the following conditions, within the past 5 years, have you or any dependents for whom you are requesting coverage:

Been tested for or diagnosed with;

Had medical treatment recommended;

Received medical 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

Yes

No

 

 

other disease or disorder of the heart, arteries, blood, or blood vessels?

 

 

 

 

 

 

 

 

 

B. Cancer or cancerous tumor?

Yes

No

 

 

 

 

 

 

 

C. Asthma, emphysema, tuberculosis, or any other disorder of the lungs or

Yes

No

 

 

respiratory system?

 

 

 

 

 

 

 

 

 

D. Diabetes? If yes, check all that apply:

Yes

No

 

 

Non-Insulin Dependent Insulin Dependent Insulin Pump

 

 

 

 

 

 

 

 

 

E. Hepatitis, or any disorder of the liver, stomach, colon, or intestines?

Yes

No

 

 

 

 

 

 

 

F. Growth disorder or a disorder of the pancreas?

Yes

No

 

 

 

 

 

 

 

G. Chronic kidney stones, or other disorders of the kidney, prostate, or bladder?

Yes

No

 

 

 

 

 

 

 

H. Reproductive organ disorders or infertility?

Yes

No

 

 

 

 

 

 

 

I. Arthritis, or any other disorder of the joints, muscles, back, or bones?

Yes

No

 

 

 

 

 

 

 

J. Mental or emotional disorder?

Yes

No

 

 

 

 

 

 

 

K. Seizures/epilepsy, paralysis, or any other disorder of the brain or nervous

Yes

No

 

 

system?

 

 

 

 

 

 

 

6

 

 

 

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70670

 

ILLINOIS STANDARD HEALTH APPLICATION – SMALL EMPLOYER

Employer Name ________________________________ Employee Name __________________________________________

 

L. HIV positive, AIDS, diseases associated with AIDS, lupus, or other disorder of

Yes

No

 

 

the immune system?

 

 

 

 

 

 

 

 

 

M. Alcohol, drug, or substance use or dependency?

Yes

No

 

 

 

 

 

 

 

N. Organ or bone marrow transplant?

Yes

No

 

 

 

 

 

2 Are you, your spouse/domestic partner, or any dependent for whom you are requesting

Yes

No

 

 

coverage currently pregnant?

 

 

 

 

Due Date: _____/_____/_________ (MM/DD/YYYY)

 

 

 

 

If yes, are multiples (twins, triplets, etc.) expected?

Yes

No

 

 

Are there any known complications, or is a cesarean section planned?

Yes

No

 

3Within the past 12 months, have you or your spouse/domestic partner

 

used any tobacco products?

Employee:

Yes

No

 

 

Spouse/Domestic Partner:

Yes

No

 

 

 

 

4

Within the past 12 months, has any applicant been prescribed medication

Yes

No

 

(other than for the common cold or flu) that is not indicated elsewhere in

 

 

 

this application?

 

 

 

 

 

 

 

5

Within the past 5 years, has any person applying for coverage been tested for or

Yes

No

 

diagnosed with, had medical treatment recommended, received medical treatment,

 

 

 

including prescription medications, or been hospitalized for any illness, injury or

 

 

 

health condition not indicated above?

 

 

 

GAdditional Information

If you answered “Yes” to any of the questions above, you must complete this section.

If additional space is required, please attach a separate sheet and be sure to sign and date that sheet.

Question Number: _________ Name of Individual: _________________________________________________________

Condition/Diagnosis: ________________________________________ Date Diagnosed (MM/YYYY): _________________

Treatment Received: ___________________________________________________________________________________

_____________________________________________________________________________________________________

Treatment ongoing? Yes No Last Treatment Date: _____________________________________________

Surgery, additional tests or treatment recommended? ______________________________________________________

Medication Prescribed (if any): __________________________________________________________________________

______________________________________________________________ Currently taking medication? Yes No

Question Number: _________ Name of Individual: _________________________________________________________

Condition/Diagnosis: ________________________________________ Date Diagnosed (MM/YYYY): _________________

Treatment Received: ___________________________________________________________________________________

_____________________________________________________________________________________________________

Treatment ongoing? Yes No Last Treatment Date: _____________________________________________

Surgery, additional tests or treatment recommended? ______________________________________________________

Medication Prescribed (if any): __________________________________________________________________________

______________________________________________________________ Currently taking medication? Yes No

 

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