Southwest Service Life Insurance Company
|
|
|
- Blanche Jones
- 5 years ago
- Views:
Transcription
1 Southwest Service Life Insurance Company UNDERWRITING GUIDE 2/ v1Proof.indd 1
2 95587v1Proof.indd 2
3 95587v1Proof.indd 3
4 Acne A A A ADD A A A Addison s Disease D A D AIDS, ARC, HIV Infection D D D Alcoholism/Alcohol Abuse or Misuse D IC D Allergies (seasonal) A A A Alopecia A A A Alzheimer s Disease D D D Anal Fissure MR A A Anemia Aplastic D IC IC HeParamolytic D IC IC Iron Deficiency Mild, single occurrence within one year MR A A over one year A A A chronic or recurrent IC IC IC Pernicious D D D Sickle Cell D D D Aneurysm within one year D IC D *over one year and operated MR A IC v1Proof.indd 4
5 Angina Pectoris MR A IC Aphasia MR IC D Arteriosclerosis MR A IC Arthritis Osteoarthritis MR A A Rheumatoid MR A A Asbestosis MR D IC Asthma MR A A Atheroma MR A IC Atrial Fibrillation MR A IC Atrial Septal Defect Unoperated D A D *Operated IC A IC Back Injury or Surgery Unoperated MR A IC *Operated IC A A Back Sprain/Strain Within 2 years MR A A Over 2 years IC A A Bell s Palsy IC IC IC v1Proof.indd 5
6 Bipolar Disorder D A IC Breast Implants MR A A Bronchitis Acute A A A Chronic Mild to Moderate MR A A Severe D D D Buerger s Disease D A IC Cancer (Malignant) Internal Within 2 years D D D Over 2 years MR D IC Skin MR IC A Candidosis (Thrush) A A A Carotid Endarterectomy Within one year D A D *Over one year MR A IC Carpal Tunnel Syndrome Cataract *Operated Within one year MR A A Over one year A A A v1Proof.indd 6
7 Cerebral Embolism, Hemorrhage, or Thrombosis Within one year D D D *Over one year MR A IC Cerebral Palsy D D D Cholecystitis & Cholelithiasis Chronic Fatigue Syndrome A A A Chronic Obstructive Pulmonary Disease... (see Emphysema) Chorea, Huntington s D D D Cirrhosis of Liver D D D Cleft Palate Club Foot Colitis Spastic MR A A Ulcerative D IC IC v1Proof.indd 7
8 Crohn s Disease D IC IC Cystic Disease Breast MR IC A Kidney D D D Ovary MR IC A Cystic Fibrosis D D D Cystitis Acute A A A Chronic MR A A Interstitial MR A A Cystocele Detached Retina Within 3 years MR A A *Over 3 years A A A Deviated Septum Diabetes Mellitus Excellent control with diet or oral medication and no other health factors (TYPE 2) MR A A All others and/or insulin required (TYPE 1) D D D v1Proof.indd 8
9 Disc Disease (Spinal) *Operated IC A A Diverticulitis & Diverticulosis MR A A Down s Syndrome D D D Drug Abuse or Addiction D IC D Duodenal Ulcer Single Episode Within 2 years MR A A Over 2 years IC A A Multiple Episodes Within 5 years MR A A Over 5 years IC A A Emphysema Mild to Moderate MR D IC Severe to Disabling (on Oxygen) D D D Endometriosis *Operated Within 2 years MR A A Over 2 years A A A Epilepsy MR A IC Esophageal Stricture/Spasm MR A A Fibrocystic Breast Disease A IC A v1Proof.indd 9
10 Fibromyalgia A A A Gastric Ulcer (See Duodenal Ulcer)... GERD MR IC A Glaucoma MR A A Gout MR A A Grave s Disease MR IC A Hayfever Mild, Seasonal A A A Moderate A A A Chronic IC A A Heart Attack Within one year D A D *Over one year MR A IC Heart Bypass Surgery Within one year D A D *Over one year MR A IC Heart Murmur IC A IC Hemophilia D D D Hemorrhoids v1Proof.indd 10
11 Hepatitis Acute, Infectious IC A IC Chronic or Recurrent (Hepatitis C) D A D Hernia (any type) *Operated Within one year MR A A Over one year A A A Herpes Zoster A A A Hydrocele Hydrocephalus D A IC Hypercholesterolemia / Hyperlipidemia MR A A Hyperglycemia (see Diabetes)... Hypertension (HBP) MR A A Hypoglycemia (see Diabetes)... Hypothyroidism / Hyperthryoidism A A A Impetigo A A A Incontinence IC A A Intestinal Obstruction MR A A Irritable Bowel Syndrome MR A A v1Proof.indd 11
12 Kaposi s Sarcoma D D D Kidney Stone(s) Stone present IC A A Stone passed or removed Single attack Within 5 years IC A A Over 5 years IC A A Multiple attacks IC A A Knee, Cartilage Injury Right Knee Left Knee Both Knees Unoperated MR MR MR A A *Operated Within 2 years MR MR MR A A Over 2 years A A A A A Liver Abscess Within 5 years MR IC IC Over 5 years A A A Lupus Erythematosus Discoid MR A A Disseminated or Systemic D D IC Lyme disease MR IC IC Manic-Depression D A D Meniere s Disease or Syndrome MR A A Meningitis Within one year MR A A *Over one year A A A Mental or Nervous Disease or Disorder (all forms) D A IC v1Proof.indd 12
13 Mental Retardation D D D Migraine Headaches Acute A A A Chronic MR A A Mitral Valve Prolapse MR A A Multiple Myeloma D D D Multiple Sclerosis D D D Muscular Dystrophy D D D Myasthenia Gravis MR A A Myocardial Infarction (see Heart Attack)... Narcolepsy MR A IC Osteomyletis Mild MR A A Severe or Recurrent MR A A Osteoporosis MR A A Otitis Media Acute A A A Chronic or Recurrent MR A A v1Proof.indd 13
14 Pacemaker Implantation Within one year D A D *Over one year MR A D Pancreatic Cyst Unoperated D D D *Operated Within 5 years MR IC IC Over 5 years A A A Pancreatitis Acute Within 5 years MR A A Over 5 years A A A Chronic or Recurrent D D D Paralysis Hemiplegia D A D Paraplegia D A D Quadriplegia D A D *Poliomyelitis IC A IC Parkinson s Disease D D D Pelvic Inflammatory Disease Peptic Ulcer Disease (see Duodenal Ulcer) v1Proof.indd 14
15 Pericarditis Single Attack Within 2 years MR A IC Over 2 years IC A A Recurrent IC A D Peripheral Vascular Disease MR A IC Phlebitis MR A A Pleurisy A A A Pneumothorax Traumatic A A A Spontaneous Single Attack IC A A Multiple Attacks MR A IC Polycythemia D IC D Psoriasis A A A Polyp (Benign) Unoperated MR D A *Operated Within 3 years MR A A Over 3 years A A A v1Proof.indd 15
16 Prostate Hypertrophy (Benign) Unoperated MR IC A *Operated Within 3 years MR A A Over 3 years A A A Prostatitis Acute A A A Chronic or Recurrent MR IC A Psychoneurosis, Psychosis D D D Pulmonary Embolism or Infarction Within one year D D D *Over one year MR A IC Pulmonary Fibrosis D D D Pyloric Stenosis *Operated Within one year MR A A Over one year A A A Raynaud s Disease or Syndrome D A IC Rectocele Renal Failure D D D v1Proof.indd 16
17 Renal Insufficiency IC IC IC Sarcoidosis D D D Schizophrenia D D D Scoliosis MR A A Seizure Disorder MR A IC Skin Cancer All except Melanoma A D A Melanoma Within 2 years D D D Over 2 years MR D IC Sinusitis Mild A A A Chronic or Recurrent MR A A Spina Bifida Under age 18 D A A Over age 18 MR A A Strabismus Stroke (Cerebrovascular Accident) Within one year D D D *Over one year MR A D v1Proof.indd 17
18 Tachycardia MR A IC Thyroid A A A Tuberculosis Active D D D *Arrested Within one year D IC IC One to five years MR IC IC Over five years (no treatment) A A A Tumor Benign Unoperated MR D IC *Operated IC IC IC Malignant (see Cancer) Urethral Stricture Varicose Veins Ventricular Septal Defect Unoperated D A IC *Operated IC A IC v1Proof.indd 18
19 Southwest Service Life Insurance Company Height MALES Underweight Decline HEIGHT & WEIGHT GUIDLINES Overweight Decline Height FEMALES Underweight Decline Overweight Decline Our New Height & Weight Chart Effective Immediately February 1st v1Proof.indd 19
20 Southwest Service Life Insurance Company Height MALES Underweight Decline HEIGHT & WEIGHT GUIDLINES Overweight Decline Height FEMALES Underweight Decline Overweight Decline Our New Height & Weight Chart Effective Immediately February 1st v1Proof.indd 20
Phoenix Remembrance Life
Phoenix Remembrance Life Field Underwriting Guide For agent use only. Not for distribution to the public as sales literature. Phoenix Remembrance Life is whole life insurance underwritten on a simplified
How much do you know about illnesses or health problems for your parents, grandparents, brothers, sisters, and/or children? 1 A lot Some None at all
Family Health History Please answer each question as honestly as possible. There are no right or wrong answers to nay of the questions. It is important that you answer as many questions as you can. We
CUMULATIVE ILLNESS RATING SCALE (CIRS)
CUMULATIVE ILLNESS RATING SCALE (CIRS) The CIRS used in this protocol is designed to provide an assessment of recurrent or ongoing chronic comorbid conditions, classified by 14 organ systems. Using the
Premium Specialty: Pediatrics
Premium Specialty: Pediatrics Credentialed Specialties include: Adolescent Medicine, Pediatric Adolescent, and Pediatrics This document is designed to be used in conjunction with the UnitedHealth Premium
Supplementary materials for:
Supplementary materials for: Cecil E, Bottle A, Sharland M, Saxena S. Impact of UK primary care policy reforms on short-stay unplanned hospital admissions for children with primary care-sensitive conditions.
Health Underwriting Guidelines CONDITION ACCEPT DECLINE A. Acne Addisons s Disease Adrenal Insufficiency
New Underwriting Guidelines Below is a general outline for Blue Cross and Blue Shield of Texas underwriting guidelines for Individual Health Products. A Acid Reflux Acne Addisons s Disease Adrenal Insufficiency
Rapid Decision Term Rate Class Criteria Guide: Standard or Better, Table B, Table D
Rapid Decision Term Rate Class Criteria Guide: Standard or Better, Table B, Table D Table Ratings for Rapid Decision Term are ONLY AVAILABLE using Fidelity Life s RAPID APP 2 (Online Application Technology)
EVIDENCE-BASED VITAMIN AND MINERAL USAGE SUMMARY TABLE (APRIL 2002)
Acne Acrodermatitis Enteropathica Adrenal Support Age Related Cognitive Decline Alcoholism/Alcohol Withdrawal Alzheimer's Disease Amenorrhoea Anaemia Angina Anorexia Nervosa Anxiety Asthma Atherosclerosis
List of Qualifying Conditions
List of Qualifying Conditions Cancer Conditions 1) Adrenal cancer 2) Bladder cancer 3) Bone cancer all forms 4) Brain cancer 5) Breast cancer 6) Cervical cancer 7) Colon cancer 8) Colorectal cancer 9)
In your own words, please write the reason you are here. Please be specific, putting in dates as necessary. Use the back of the form if needed.
Name: SS# In your own words, please write the reason you are here. Please be specific, putting in dates as necessary. Use the back of the form if needed. Patient Medical, Surgical and Family History Review
Term & Universal Life Guidelines - Simplified
- G.U.L. AIDS Alcoholism Within past 4 years: Within past 4 years: Within past 5 years: After 5 years, without relapse, no current use: : After 5 years since treatment: Less than 5 years: POSSIBLE STANDARD
UnitedHealth Premium Physician Designation Program Episode Treatment Groups (ETG ) Description and Specialty
UnitedHealth Premium Physician Designation Program Episode Treatment Groups (ETG ) Description and Specialty 666700 Acne Family Medicine, Internal Medicine, Pediatrics 438300 Acute Bronchitis Allergy,
CHRONIC TREATMENT GUIDELINES
CHRONIC TREATMENT GUIDELINES REGISTRATION OF CHRONIC CONDITIONS You can only access benefits for chronic medication, as listed below, if your prescribing/treating doctor or pharmacist registers your chronic
SUPPLEMENTARY MATERIAL
SUPPLEMENTARY MATERIAL Deep Patient: An Unsupervised Representation to Predict the Future of Patients from the Electronic Health Records Riccardo Miotto 1,2, Li Li 1,2, Brian A. Kidd 1,2, and Joel T. Dudley
FORESTERS: COLUMBIAN FINANCIAL GROUP: Smart U.L. Strong Foundation. Safe Shield. After 5 years, without relapse, no current use: ACCEPT
AI Alcoholism Within past 4 years: Within past 4 years: Within past 5 years: After 5 years, without relapse, no current use: Within past 10 years: Alcohol Abuse: After 5 years since last treatment and
Internal Medicine End of Rotation
Internal Medicine End of Rotation EXAM TOPIC LIST CARDIOVASCULAR Angina pectoris Cardiac arrhythmias/conduction disorders Cardiomyopathy Congestive heart failure Coronary vascular disease Endocarditis
Cannot consider Cannot consider Cannot consider
Field Home Office Absence Seizures Petit Mal Minor Epilepsy These are names for generalized seizures that are manifest by brief attacks of altered consciousness, confusion, a dazed look or staring. Date
PATIENT HISTORY FORM. Patient Name: Date of Birth AGE: Primary Care Provider:
Date: PATIENT HISTORY FORM Patient Name: Date of Birth AGE: Primary Care Provider: What medical problem brings you to our clinic? When did this begin? What do you think caused it? (Circle One) Work Injury
Intensity: 0-10 (10 is the worse pain you have ever experienced in your life that you would want to jump from a building, 0 is no pain)
Patient Questionnaire: Name: Date: Occupation: Date of Birth: Age: Sex: Male Female Referring Physician: Chief Complaint: Describe your Pain: sudden onset gradual constant intermittent worsening improving
Anatomy, Physiology, & Disease 3rd Edition, 2016
A Correlation of Anatomy, Physiology, & Disease 3rd Edition, 2016 To the Mississippi Curriculum Framework Health Sciences Core II 2008 CTE Health Sciences Frameworks Table of Contents Unit 6: Vital Organs
Episodes of Care Risk Adjustment
Episodes of Care Risk Adjustment Episode Types Wave 1 Asthma Acute Exacerbation Perinatal Total Joint Replacement Wave 2 Acute Percutaneous Coronary Intervention COPD Acute Exacerbation Non-acute Percutaneous
New Patient Paperwork
New Patient Paperwork Date: Phone: Patient: Last Name First Name Initial Street Address: City/State/Zip Code: Sex: M F Age: Birthdate: Single Married Widowed Separated Divorced Email: Newsletter? Y N Insured
COMMON SENSE PLAN. United American CS1 Guide to Field Underwriting. BASIC HOSPITAL/SURGICAL Expense Plan. General Rules:
United American CS1 Guide to Field Underwriting COMMON SENSE PLAN BASIC HOSPITAL/SURGICAL Expense Plan General Rules: UA'S PRIVACY AND DISCLOSURE INFORMATION UNDERAGE HEALTH SERIES EDITION (FORM UAPDI-UH)
Field Underwriting Quickview
Field Underwriting Quickview For a selected list of medical conditions, the Field Underwriting Quickview outlines possible classifications and the circumstances when coverage may not be. For coverage provided
DATE OF BIRTH: MELANOMA INTAKE
MELANOMA INTAKE GENERAL INFORMATION How was your first diagnosed? (Check the diagnosis that describes your condition.) Melanoma Merkel Cell Carcinoma Squamous Cell Carcinoma Basal Cell Carcinoma Other
WASHINGTON UNIVERSITY SCHOOL OF MEDICINE. Cranial Health History Form
WASHINGTON UNIVERSITY SCHOOL OF MEDICINE Cranial Health History Form Welcome to the Neurosurgery Department at Washington University. To help us treat you, please fill this form out completely. Your Name:
Patient Name (First, Middle, Last) Height Weight. Ethnicity Race Language. Address. City State Zip. Home Phone Cell Phone. Work Phone Other Phone
Patient Name (First, Middle, Last) Height Weight Date of Birth Social Security # Gender Male Female Ethnicity Race Language Address City State Zip Home Phone Cell Phone Work Phone Other Phone Email Occupation
Patient Interview Form
Patient Interview Form Patient Information First Name: MRN: Age: Last Name: Date Of Birth: tes: Contact Preference Email Telephone call/leave message Patient declines to specify Email Please check one
ICD-9-CM CODING FUNDAMENTALS CODING EXERCISES
Steps to Accurate Coding Underline the main term, then locate code: Stenosis of Carotid Artery Transient Ischemic Attack Gastrointestinal hemorrhage Degenerative Joint Disease Coronary Artery Disease Alcoholic
Medical Reference Library Table of Contents
Medical Reference Library Table of Contents Alcoholism Anemia Anxiety Abdominal Aortic Aneurysm Asthma Atrial Fibrillation Attention Deficit Hyperactivity Disorder (ADHD) Barrett s Esophagus Bipolar Disorder
MEDICAL HISTORY. Previous Nephrologist. Medication taken Insulin Oral Both. Who manages your diabetes? Blindness Yes No Hearing Problems Yes No
MEDICAL HISTORY Please mark YES or NO and fill in appropriate blanks as needed Chronic Yes No If yes, year diagnosed Previous Nephrologist Transplant Yes No If yes, date Donor type Living Deceased Related
Notifiable Medical Conditions
Notifiable Medical Conditions A Acoustic neuroma Addison s disease Agoraphobia AIDS Alcohol problems Alzheimer s disease Amyotrophic Lateral Sclerosis - see Motor Neurone Disease Amputations Aneurysm Angina
Health History Questionnaire
LTC Health History Questionnaire The first step in long-term care expense planning is determining insurability. Long-term care insurance is medically underwritten. Health history will determine carrier,
BOTLHE MEDICAL AID SCHEME - APPLICATION FORM
What you must do 1. 2. 3. 4. 5. Once you have submitted your application form, here is what will happen: - If any details are missing or if we need more information for underwriting purposes, we will contact
SECTION I: ACTIVE DIAGNOSES. Active Diagnoses in the Last 7 Days
SECTION I: ACTIVE DIAGNOSES Intent: The items in this section are intended to code diseases that have a relationship to the resident s current functional status, cognitive status, mood or behavior status,
Medical Mental Health Reference Data. Florida Safe Families Network FSFN. May 12, 2017 Page 1 FSFN. Medical Mental Health. Page: Tab Name: Field Name:
Mental Health Profile Alcohol, Drugs, Marijuana, Solvents Frequency Daily Isolated Known Use / Unknown Frequency Occasional/Monthly Use Weekly Medical History Condition Type Dental Medical Mental Medical
SHMI diagnoses July 2016 to June 2017
SHMI diagnoses July 2016 to June 2017 0.0 100.0 200.0 300.0 400.0 500.0 600.0 700.0 Pneumonia (except that caused by tuberculosis or sexually transmitted disease) Acute cerebrovascular disease Septicaemia
Northwest Georgia Surgical Specialists, PC PAST MEDICAL HISTORY
orthwest Georgia Surgical Specialists, PC Medical History Form ame Date of visit Last First MI Day ear Date of Birth Age Gender Marital Status Height Weight Day ear Referring Doctor Reason for Visit PAST
NurseAchieve. CHAPTERS INCLUDED IN THE NURSEACHIEVE COMPREHENSIVE NCLEX REVIEW NURSING SKILLS AND FUNDAMENTALS:
NurseAchieve www.nurseachieve.com CHAPTERS INCLUDED IN THE NURSEACHIEVE COMPREHENSIVE NCLEX REVIEW NCLEX TEST STRATEGIES: NCLEX EXAM OVERVIEW TEST TAKING STRATEGIES NURSING SKILLS AND FUNDAMENTALS: ADMINISTRATION
CHRONIC MEDICINE PROGRAMME GENERAL INFORMATION LETTER
RAND WATER MEDICAL SCHEME RAND WATER MEDICAL SCHEME CHRONIC MEDICINE PROGRAMME GENERAL INFORMATION LETTER LIST OF CHRONIC CONDITIONS Conditions covered under s chronic medication benefit are detailed below.
ENROLLMENT : Line of Business Summary
ENROLLMENT : Line of Business Summary Date Range : JAN 2017 through DEC 2017 COMPREHENSIVE MAJOR MEDICAL Print Date : 1/19/2018 9:43:49AM Page 1 of 1 Month Year Single 2 Person : Emp/Spouse 2 Person :
Detailed medical questionnaire Underwritten by Co-operators Life Insurance Company.
canadian expatriates visitors to canada inpatriates to canada Detailed medical questionnaire Underwritten by Co-operators Life Insurance Company. How to complete this form: Complete one form for each person
PATIENT INFORMATION (Please print all information) Date:
320 Lillington Ave Suite 101 Charlotte, NC 28204-3189 Phone: 704.362.4403 Fax: 704.362.4405 Please fill out the following form completely so that we may obtain the necessary information for our files and
City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
Table of Contents: 1. Neurology
Table of Contents: 1. Neurology a.) Alzheimer's Disease b.) Brain Abscess c.) Brain Death d.) Cerebral Vascular Disease e.) Headache f.) Meningitis g.) Multiple Sclerosis h.) Muscular Dystrophy i.) Parkinson's
Using 3-Digit ICD-9-CM Codes with the Elixhauser Comorbidity Index
Congestive Heart Failure 398.91 Rheumatic heart failure (congestive) 398 Other rheumatic heart disease 402.01, 402.11, 402.91 402 Hypertensive heart disease 404.01, 404.03, 404.11, 404.13, 404.91, 404.93
Georgia Department of Human Services BIRTH FAMILY BACKGROUND INFORMATION FOR CHILD. Name of Child Date of Birth Sex Race Hispanic Ethnicity Yes No
Georgia Department of Human Services BIRTH FAMILY BACKGROUND INFORMATION FOR CHILD Name of Child Date of Birth Sex Race Hispanic Ethnicity Yes No Legal County (DHS Child) Resident County (Non-DHS Child)
Medical Impairment Guidelines
Medical Impairment Guidelines Introduction The Individual Life Operations, Underwriting Division, is responsible for the protection of the company s mortality and morbidity expectations inherent in pricing
INDIVIDUAL AGENT GUIDELINES
OVERVIEW The following agent guidelines should be used as a reference tool only to the probable underwriting outcome for the enclosed listed conditions. The listed conditions are the most commonly seen
Maineville Family Physician. History and Review of Systems. Name: DOB
Maineville Family Physician History and Review of Systems Name: DOB History of Medical Problems: Please circle the conditions which you have been diagnosed with by a physician and the year or age you were
Eligibility. Information about you. Information about your agent Only complete this section if you have an agent
Visitors to Canada Detailed medical questionnaire Underwritten by CUMIS General Insurance Company, a member of The Co-operators group of companies. How to complete this form: Complete one form for each
Patient Intake Form for Allegany Ear, Nose, & Throat
Patient Intake Form for Allegany Ear, se, & Throat Patient Name: What brings you to the office today? Who is your primary care doctor? Please list your current medications: Are you allergic to any medications?
Measuring Long-Term Conditions in Scotland - A summary report
Measuring Long-Term Conditions in Scotland - A summary report Introduction This summary report provides insight into: What are the most common long-term conditions in Scotland? What is the population prevalence
Eligibility. Information about you. Information about your agent Only complete this section if you have an agent
Canadian Expatriates Visitors to Canada Inpatriates to Canada Detailed medical questionnaire Underwritten by CUMIS General Insurance Company, a member of The Co-operators group of companies. How to complete
J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health
J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health Patient Clinical Information Questionnaire 1.0 Date of Questionnaire Completion; / / 2.0 Patient Data 2.1 Name:
SCHNEIDER MEDICAL GROUP, PA History Intake Form (Please Print)
History Intake Form Patient Name: Date of Visit: Briefly State the reason for the visit: Date of Birth: Physician Use Only - History and Present: 1. 2. 3. 4. 5. Page 1 of 10 Review of Symptoms HEAD NO
Patient Medical Information. Last. Sex: M / F Age: Date of Birth: Home Address: City: State: Zip Code: Business Address: City: State: Zip Code:
Patient Medical Information Name: First Middle Last Sex: M / F Age: Date of Birth: Social Security # Driver s License # Home Address: City: State: Zip Code: Home Phone: Occupation: Cell: Employer: Business
Field underwriting pocketbook for life and critical illness insurance
500-5000 Yonge Street Toronto, Ontario M2N 7J8 www.ivari.ca ivari and the ivari logos are trademarks of ivari Canada ULC. ivari is licensed to use such marks. BW-LP1540 9/15 Field underwriting pocketbook
QUESTION. Personal Behavior History. Donor Genetic History. Donor Medical History. Family Medical History PERSONAL BEHAVIOR HISTORY. Never N/A.
Donor 4576 Medical Profile S Personal Behavior History Donor Genetic History Donor Medical History Family Medical History PERSONAL BEHAVIOR HISTORY Current alcohol use: If yes, oz./week and type of alcohol:
CENTRAL COAST ORTHOPEDIC MEDICAL GROUP Medical History Questionnaire GENERAL INFORMATION
GENERAL INFORMATION Last Name: First Name: What name do you prefer to be called? Age: DOB: / / Height: Weight: Left or Right Handed : Right Left Marital Status: M S D W Name of spouse or significant other:
79 HCCs CMS-HCC Risk Adjustment Model. ICD-10-CM to CMS-HCC Crosswalk. Over 9,500 ICD-10-CM codes map to one or more.
2017 CMS-HCC Risk Adjustment Model Over 9,500 ICD-10-CM codes map to one or more 79 HCCs ICD-10-CM to CMS-HCC Crosswalk CMS-HCC Model On April 4, 2016, the Centers for Medicare & Medicaid Services (CMS)
UNDERWRITING GUIDELINES. Individual Insurance
UNDERWRITING GUIDELINES Individual Insurance TABLE OF CONTENTS About this guide... 4 Medical conditions Asthma...5 Auricular fibrillation...5 Autism...5 Bariatric surgery...5 Barrett s esophagus...5 Cancer
Our Specified Illness Benefit Is Now Even Better.
Our Specified Illness Benefit Is Now Even Better. Now Covering 47 Specified Illnesses 20 Partial Payment Illnesses Enhancements to our Specified Illness Benefit We have made enhancements to our Specified
New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care
Page 1 of 7 Patient Demographics First Name* Last Name* Date Of Birth* Home Phone* Mobile Phone Phone Gender* Email Preferred Communication Street Address 1* Street Addresss 2 Zip* City* State* Emergency
FROST FAMILY MEDICINE
Patient Information (Please Sign and return to Receptionist) Home Phone Day Phone Cell Phone E-mail Driver s License # Preferred Language Race Soc Sec # Gender: Male Female Marital Status: Single Married
Welcome to Medina Family Chiropractic and Acupuncture!
Welcome to Medina Family Chiropractic and Acupuncture! Please fill out this form and return it to the front desk. Let us know if you have any questions! Personal information Date: First name: Middle name:
Evolve180 / Ideal Northwest Health Profile
Evolve180 / Ideal Northwest Health Profile ABOUT YOU First Name: Last Name: Address: City: State: Zip: Phone: Email: Date of Birth: Age: Height: Occupation: How did you find out about our program? Marital
Student Outline. Improving Transportation Safety: Commercial Driver Medical Examiner Training CHAPTER 1. General FMCSA Information
Student Outline CHAPTER 1 General FMCSA Information FMCSA Mission Statement / Dedicated to Safety / NRCME Important Definitions Regulations Vs. Medical Guidelines Privacy and the Medical Examination 13
Nutrition Consultation Intake Form Please write or print clearly
Artemis in the City, LLC Danielle Heard, MS, MS, HHC Clinical & Functional Nutritionist ph: 866-330-5421 fx: 212-535-3234 www.artemisinthecity.com Nutrition Consultation Intake Form Please write or print
Personal Information. Client Questionnaire. Basic Information. Date of Birth. Male Female Other Not Specified. Contact Information
Client Questionnaire Personal Information Basic Information First Name Last Name Date of Birth Male Female Other Not Specified Contact Information Email Preferred Phone Cell Address City State Zip Emergency
Pharmacy Prep. Qualifying Pharmacy Review
Pharmacy Prep 2014 Misbah Biabani, Ph.D Director, Tips Review Centres 5460 Yonge St. Suites 209 & 210 Toronto ON M2N 6K7, Canada Luay Petros, R.Ph Pharmacy Manager, Wal-Mart, Canada 1 Disclaimer Your use
CHIEF COMPLAINT. Patient history
Patient Name: Appointment date: E-mail Address: Referred by: (Doctor s name and phone #) CHIEF COMPLAINT Which shoulder is painful? Right Left Both shoulders equal Right more painful than Left Left more
STEPHEN P. NONN OFFICE OF THE CORONER MADISON COUNTY, ILLINOIS 157 MAIN STREET SUITE 354 EDWARDSVILLE, IL
MAIN OFFICE: (618) 692-7478 MORGUE: (618) 296-4525 FAX: (618) 692-6042 FAX: (618) 692-9304 STEPHEN P. NONN OFFICE OF THE CORONER MADISON COUNTY, ILLINOIS 157 MAIN STREET SUITE 354 EDWARDSVILLE, IL. 62025-1962
Liver Health: Do you have liver problems? Yes No If so, please specify:
Medical History General Last Name: First Name: Date of Birth: Age: Contact Number: Are you in good health to the best of your knowledge Medical Information: Please list any physicians you see and their
S2 File. Clinical Classifications Software (CCS). The CCS is a
S2 File. Clinical Classifications Software (CCS). The CCS is a diagnosis categorization scheme based on the ICD-9-CM that aggregates all diagnosis codes into 262 mutually exclusive, clinically homogeneous
Eligibility Requirements: Identifying Potential Members for Health Home Services
Eligibility Requirements: Identifying Potential Members for Health Home Services Individuals previously receiving TCM services through a COBRA HIV or OMH TCM program, receiving substance use case management
IN-VITRO FERTILIZATION WITH DONATED OOCYTES COMPREHENSIVE HISTORY OF RECIPIENT COUPLE (HUSBAND)
Personal History Name Date of Birth Home Address Home Phone Work Phone Type of Employment Social Security # Medical Insurance Marital Status Religion Highest education degree (high school, college, graduate
SURGERY SPECIALTY PATIENT HEALTH HISTORY
SURGERY SPECIALTY PATIENT HEALTH HISTORY Chief Complaint - Please describe the problem that brings you into the office today: Allergies 1. Do you have any allergies? if so, please list To Medications?
Medical conditions that preclude entry
Medical conditions that preclude entry If you have or have had any of the conditions listed below, it means that you do not meet the current medical standard required to enter Military Service: NB: This
CHRONIC MEDICATION PROGRAMME INCLUDES PRESCRIBED MINIMUM BENEFIT CHRONIC DISEASE LIST (CDL)
CHRONIC MEDICATION PROGRAMME INCLUDES PRESCRIBED MINIMUM BENEFIT CHRONIC DISEASE LIST (CDL) A. GENERAL INFORMATION LIST OF CHRONIC CONDITIONS Conditions covered under KeyHealth s chronic medication benefit
WITBANK COALFIELDS MEDICAL AID SCHEME (WCMAS) CHRONIC MEDICINE PROGRAMME GENERAL INFORMATION LETTER
WITBANK COALFIELDS MEDICAL AID SCHEME (WCMAS) CHRONIC MEDICINE PROGRAMME GENERAL INFORMATION LETTER The Prescribed Minimum Benefit Chronic Disease List In terms of the Medical Scheme Act Regulations that
List of Video Titles. Allergy. Cardiology. Dermatology
List of Video Titles Allergy Allergic Rhinitis Anaphylaxis Angioedema Asthma Asthma Atopic Dermatitis Contact Dermatitis Metered-Dose Inhaler Metered-Dose Inhaler Peak Flow Meter Peak Flow Meter Sinusitis
Northern Monmouth County Medical Associates
Northern Monmouth County Medical Associates 195 Route 9; Suite 112 Manalapan, NJ 07726 (732)345-2070 FAX: (732) 345-2072 DATE: COMPLETE MEDICAL HISTORY FORM NAME: AGE: DATE OF BIRTH: I. CHIEF COMPLAINT:
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
ANY FAMILY HISTORY OF ANEURYSM OR DVT?
NAME: D/O/B: DATE: MR# WHAT PROBLEM(S) BRINGS YOU HERE TODAY? WHO SENT YOU TO US? DOCTOR/OTHER WHICH DOCTOR? WHAT SURGERY HAVE YOU HAD AND WHEN? (LIST) 1. 2. 3. 4. 5. 6. 7. HOW MUCH ALCOHOL DO YOU DRINK
InterQual Level of Care 2018 Index
InterQual Level of Care 2018 Index Rehabilitation Criteria Index Words by Subset The Index is an alphabetical listing of conditions and/or diagnoses designed to guide the user to the criteria subset where
Barbara G. Wells, PharmD, FASHP, FCCP, BCPP Dean and Professor School of Pharmacy, The University of Mississippi Oxford, Mississippi
Barbara G. Wells, PharmD, FASHP, FCCP, BCPP Dean and Professor School of Pharmacy, The University of Mississippi Oxford, Mississippi Joseph T. DiPiro, PharmD, FCCP Panoz Professor of Pharmacy, College
Salt Lake Orthopaedic Clinic Initial Visit Form
Salt Lake Orthopaedic Clinic Initial Visit Form Name: Today s Date: Date of Birth: Age: Height: Weight: Handedness (R/L): Referring Physician: Primary Care Physician: Chief Complaint Why are you seeing
intake form About You : General Health Information: Page 1`of 5 State/Province: Country: Zip/Postal Code: Address:
intake form Page 1`of 5 About You : Name: Sex: Male Female Address: City: State/Province: Country: Zip/Postal Code: Home Phone Number: Mobile Phone Number: Email Address: Birthday: Marital Status: Married
SCHEDULE OF CONTINUING EDUCATION COURSES FOR RN s and CNAs. January 2018 WALK INS ARE ACCEPTED BUT WE ADVISE STUDENTS TO PRE-REGISTER BEFORE THURSDAY
SCHEDULE OF CONTINUING EDUCATION COURSES FOR RN s and CNAs January 201 DATE DAY TIME TOPICS January 04 January 11 January 1 January 25 9:00AM 9:00AM 9:00AM 9:00AM 1. Understanding Fibromyalagia 2. Diabetes
LECOM Health Ophthalmology
Patient Name: Date of Birth: New Patient Questionnaire Your answers will be used by your healthcare provider get an accurate history of your medical conditions and ocular concerns. If you are uncomfortable
Alivia Acupuncture Clinic, LLC. Address. City State Zip. . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone
Alivia Acupuncture Clinic, LLC Karla Sourasky Olmos, L. Ac Patient Information Name Age Date of birth Address City State Zip Email Home Phone Work phone Cell Phone Marital Status Single Married Divorced
Past Medical History: Medical problems pertaining only to you:
Instructions: Place an X in boxes that apply to you. Make no marks in boxes that do not apply to you. Complete all sections Past : Medical problems pertaining only to you: Cardiac / Heart I have no history
Feil & Oppenheimer Psychological Services
Feil & Oppenheimer Psychological Services 260 Waseca Ave. Barrington, RI 02806 401-245-4040 Fax: 401-245-1240 feiloppenheimer@gmail.com Adult Patient Questionnaire Name: Today's Date: Address: Home Phone:
SCHEDULE OF CONTINUING EDUCATION COURSES FOR RN s and CNAs. January 2019
January 2019 DATE DAY TIME TOPICS TOTAL January 03 1. Alcoholism 2. Nutrition for the Elderly 3. Uterine Fibroids 4. HIPAA 5.Arthritis 6. Childhood Obesity January 10 1. Understanding Epilepsy: Latest
PLEASE LET US KNOW YOUR REASON FOR TODAY S VISIT : CURRENT MEDICATIONS (WITH DOSAGE) PLEASE INCLUDE VITAMINS AND HERBAL MEDICATIONS:
1 NAME: DATE OF BIRTH PLEASE LET US KNOW YOUR REASON FOR TODAY S VISIT : CURRENT MEDICATIONS (WITH DOSAGE) PLEASE INCLUDE VITAMINS AND HERBAL MEDICATIONS: PAST MEDICAL HISTORY (YOUR MEDICAL HISTORY) :
Initial Consultation
Today s Date: Initial Consultation Thank you for choosing Apollo Health and Wellness. Please take your time to fill out this form. It will help us to concentrate on areas of your health that need attention
Supplementary appendix
Supplementary appendix This appendix formed part of the original submission and has been peer reviewed. We post it as supplied by the authors. Supplement to: Williams CM, Maher CG, Latimer J, et al. Efficacy
Mailing Address: Street City Zip
First Middle Last Mailing Address: Primary Phone: Street City Zip Secondary Phone: Date of Birth: Male Female SSN: Emergency Contact Phone: Marital Status: Single Race: American Indian or Alaska Native