Application For Enrollment Form (Page 3 of 4) in pdf

Application For Enrollment Form Page 3

YES

Have you or any applying family member received any counseling, medical advice, care or treatment for

symptoms of depression, anxiety, panic attack, nervousness, schizophrenia, attention deficit disorder, mental or

emotional disorder, behavioral problem or for any other reasons not mentioned previously?

Have you or any applying family member ever had surgery of any kind including reconstructive or cosmetic,

prosthesis, stents, implants, retained hardware, organ transplant or other surgery for any other reasons?

Have you or any applying family member ever had abnormal laboratory results, X-rays, EKG, Echocardiogram,

ultrasound, nerve condition test, MRI, CT scan or other procedure?

Have you or any applying member advised to undergo further testing, treatment, surgery or organ transplant

which has not yet been performed by a physician, dentist or other health providers?

Have you or any applying family member ever had any application for health or life insurance declined,

postponed or restricted in any way?

Are you or any applying family member disabled, hospitalized or receiving medical care in the home at this time?

Have you or any applying family member ever had a pregnancy resulting in cesarean section or is one

anticipated?

Within the past five (5) years, has anyone named in this application had any examination, hospitalization,

treatment, medical advice or surgery not mentioned above?

If you answered “Yes” to any of the questions above, please give details below.

Name of Condition

Dates of Treatment

Question

Ongoing

Name of Physician,

Name of Family Member

and Type of

From and To

Number

(Yes/No)

Clinic/Hospital

Treatment received

(mm/dd/yy)

If more space is required, provide additional details on a separate sheet of paper. Please sign and date the

additional sheet used.

10.

FOR FEMALE APPLICANTS ONLY (Subscriber or Spouse)

When was your last menstrual period?

If pregnant, when is the expected date of delivery?

Are you or any applying family member currently taking any medication or have you taken any medication in the past twelve

11.

(12) months? If yes, please list below.

Name and dosage of medication

Dates of Medication

Ongoing

Name of Physician,

Name of Family Member

and condition for which

intake, From – To

(Yes/No)

Clinic/Hospital

medication was prescribed

(mm/dd/yy)

SW-APP PART II 02/12

Application For Enrollment Form Page 3

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