SKCA Health Questionnaire

Southwest Kansas Chamber Alliance Health and Wellness Plan Health Questionnaire
Name of Local Chamber*
Name of Employer (Or Enter Individual or Retiree)*
Employee Full Name*
Employee Residence Zip Code*
Email Address *

Confirmation Emailexample@example.com
Phone Number*

Area CodePhone Number
Preferred Plan Option*

Plan A - $1,000 Ind./$2,000 Fam. DeductiblePlan B - $2,500 Ind. / $5,000 Fam. DeductiblePlan C - $5,500 Ind. / $11,000 Fam. DeductiblePlan D - $4,000 Ind. / $8,000 Fam. Deductible (HSA Eligible)Plan E - $7,900 Ind. / $15,800 Fam. Deductible (DPC Option)
Preferred Prescription Option*

Plan 1 - Standard Copay $1/$75/$150/$250Plan 2 - 50% Coinsurance, $1 Generic CopayPlan 3 - Specialty Drugs Excluded, $1/$75/$150 Copay
Health Plan Enrollment Option*

Employee OnlyEmployee/SpouseEmployee/Child(ren)FamilyI Decline Participation
Status*

SingleMarriedDivorcedWidowedRetired

List the Family Members that WILL BE On Your Health Plan*

	Name	Date of Birth	M/F	Tobacco Use	Height	Weight
Employee
Spouse
Dependent
Dependent
Dependent
Dependent
Dependent
Dependent

1. Have you or any person that will be covered on your health plan been diagnosed or treated for any of the following conditions in the past 5 years? *

	Yes	No
Cardiac Disorder
Cancer
Diabetes
Kidney Disorder
Respiratory Disorder
Liver Disorder
High Blood Pressure
AIDS
Alcohol/Drug Abuse
Mental/Nervous Disorder
Neuromuscular Disorder
Stomach/Gastrointestinal Problems
Seizures/Convulsions/Epilepsy
Arthritis/Back/Bone/Joint Disorder

2. Have you or any person that will be covered on your health plan had an application for insurance declined, postponed, rated or otherwise modified? *
3. Have you or any person that will be covered on your health plan had any medical conditions in the past 24 months requiring medical care, prescription management or hospitalization in the amount of $5,000 or more? *
4. Have you or any person that will be covered on your health plan anticipating hospitalization or surgery, or had any surgery or hospitalization recommended that has not been performed? *
5. Are you or any person that will be covered on your health plan currently pregnant or suspect they may be pregnant? *

If 'YES' was answered to any of questions 1-5 above please give additional detail in the space provided below. If you answered NO to 1-5 enter NONE in the Question #1 row.*

	Family Member	Disease/ Diagnosis/ Treatment	Date of Onset Month/Year	Date Last Seen By Physician	Remaining Symptoms or Problems
Question #1
Question #2
Question #3
Question #4
Question #5

6. Prescriptions/Medications - Please list any medications, prescriptions or injections taken in the past 12 months. This needs to be answered on you or any person that will be covered on your health plan. If no one takes any medication enter NONE in the Medication #1 row.*

	Family Member	Medication Name	Dosage	Medical Condition
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5

AUTHORIZATION: My signature below hereby authorizes any physician, medical practitioner, hospital, clinic, or other medical or medically related facility, insurance company, or other organization, institution or person that has any records or knowledge pertaining to the health of me or my dependents listed on this form to provide such information to Corporate Plan Management (Health Plan Administrator). A photographic copy of this authorization shall be considered permissible. This authorization will remain in effect for six (6) months from the date below. SIGNATURE*

Clear
Date*

MonthDayYear
Date
In accordance with the HIPAA Privacy Laws and Protected Health Information (PHI), CPM may disclose Summary Health Information for the purposes of obtaining premium bids for the proposed Plan only. All electronically submitted and disseminated PHI is conducted with HIPAA compliant encryption technology.
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Southwest Kansas Chamber Alliance Health and Wellness Plan Health Questionnaire