Unified Health Form - Three Insurances

💡 Instructions: This form contains health questions for three different insurances. Expand only the sections corresponding to the insurances you are applying for. All questions are confidential and protected under HIPAA.

👤 Client Information

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💡 Important information: Please complete your basic details. This information is confidential and protected by HIPAA.

Full Name

Date of Birth (DOB)

Phone Number

🌡️General Health Questions

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1. Have you tested positive for HIV exposure or been diagnosed with AIDS in the last 10 years?

Yes

Date of diagnosis

2. Have you been hospitalized for any medical condition in the last 5 years?

Yes

Reason

Date

3. Do you currently take prescription medications regularly?

Yes

List of medications

4. Do you have any pending medical tests or recent abnormal results?

Yes

Details of pending/abnormal tests

🔬Cancer Insurance

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1. Have you been diagnosed with cancer or any malignant disease in the last 10 years?

Yes

Type of cancer

Date of diagnosis

Are you currently in treatment?

Yes

2. Have you had surgery related to cancer?

Yes

Type of surgery

Date

3. Have you received chemotherapy, radiation therapy, or other cancer treatment?

Yes

Type of treatment

Treatment dates (Ex: Jan 2023 - Mar 2024)

4. Are you currently in remission?

Yes

N/A

❤️Heart Attack/Stroke Insurance

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⚠️ IMPORTANT: For this specific insurance, if ANY answer is "Yes", the application will be rejected according to Aetna's terms.

1. In the last 6 months, have you been treated or taken medication for uncontrolled high blood pressure?

Yes

Prescribed medications

2. In the last 5 years, have you had or been recommended for heart surgery, angioplasty, pacemaker, or defibrillator?

Yes

Type of procedure

Date of procedure

3. In the last 5 years, have you received medical advice or taken medication for heart or circulatory system diseases?

Yes

Type of disease (Ex: Arrhythmia, heart failure)

4. In the last 5 years, have you received medical advice or taken medication for a myocardial infarction, heart attack, stroke, or TIA?

Yes

Type of event

Date of event

🏥Hospital Indemnity Flex

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💡 Note: This insurance pays a fixed benefit for each day of hospitalization. It complements other medical insurances.

1. Have you had any surgery or surgical procedure in the last 5 years?

Yes

Type of surgery

Date

2. Have you received major medical treatments (chemotherapy, radiation, dialysis, etc.) in the last 5 years?

Yes

Type of treatment

Treated condition

3. Have you been diagnosed with diabetes (type 1 or type 2) in the last 5 years?

Yes

Type of diabetes

4. Have you been diagnosed with chronic respiratory, kidney, liver, or nervous system diseases in the last 5 years?

Yes

Type of condition(s) (Ex: COPD, kidney failure, cirrhosis, epilepsy)

🔒 Confidentiality: All medical information provided is confidential and protected under HIPAA laws. It will only be used to determine insurance coverage eligibility.