Eligibility. Information about you. Information about your agent Only complete this section if you have an agent
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1 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 person applying for insurance. Answer all questions on the form. If you re unsure about your answers, please talk to your physician first. Applicant, legal guardian or power of attorney must sign and date the form. If you have any questions about this form, you can reach us toll-free at: If your application is missing information or isn t signed and dated, we ll have to follow up with you or your agent/broker and it will take longer to process your application. For the complete terms, conditions, limitations and exclusions please refer to the policy. Mail, fax or it back to us AZGA Service Canada Inc. o/a Allianz Global Assistance Underwriting Department 250 Yonge Street, Suite 2100 Toronto, Ontario M5B 2L7 Canada Fax: or directuw@allianz-assistance.ca Eligibility 1. Coverage is T AVAILABLE to any individual who, as of the effective date: a) has been diagnosed with a terminal illness; or b) has been diagnosed with stage 3 or 4 cancer; or c) has received treatment for any cancer ( than basal or squamous cell skin or breast cancer treated only with hormonr therapy) in the past 3 months; or d) requires assistance with activities of daily living as the result of a medical condition or state of health. You are eligible to apply for coverage if you meet the eligibility requirements stated. Do you confirm that you are eligible to apply? YES Information about you Last name First name Date of birth M F Previous Allianz Global Assistance policy # s (if known) Street Apt # City Province Postal code Phone Fax Information about your agent Only complete this section if you have an agent Who should we contact? you your agent Agent s name Send correspondence by Agent s code Fax Attention Ready to begin? Please go to the next page to get started. Page 1 of 5
2 Details about your travel plans Destination (city, state or country) Departure date (MM/DD/YYYY) Return date (MM/DD/YYYY) What type of coverage do you want? Visitors to Canada Plan $10,000 $25,000 $50,000 $100,000 $150,000 $300,000 Your medical Information 1. Have you smoked or used any tobacco products in the last 5 years? YES Height ft/ in cm 2. When was the last visit to your physician or medical clinic? (mm/dd/yyyy) Weight lbs kg Reason for visit/results (diagnosis, medications prescribed, follow-up appointments, investigations or treatments, surgery recommended or scheduled) 3. Have you been advised by a physician to have a test, investigation or surgery that you haven t had yet? YES please provide details Your medical conditions Check YES or for each group of conditions Check YES if you ve ever had symptoms, investigations or treatment for any of the conditions in the group, then check the box beside the specific condition you have. If you have more than one condition, check the box for every condition that you have. Auto-immune disorder Lou Gehrig s disease Blood disorder idiopathic thrombocytopenic purpura (ITP) scleroderma acquired immune deficiency (AIDS) or human immunodeficiency virus (HIV) multiple sclerosis hemochromatosis sickle-cell anemia anemia thrombophilia (hypercoagulability) systematic lupus erythematosis sarcoidosis any location myasthenia gravis hemophilia (hypocoagulability) spleen removed High blood pressure, cholesterol or water retention high blood pressure not taking medication taking medication medications high cholesterol not taking medication taking medication medications treated for water retention or edema in the last 12 months Please continue to the next page to tell us about symptoms, investigations and treatments. Page 2 of 5
3 Diabetes Blood Vessels pre-diabetes diet-controlled diabetes aneurysm repaired? YES location: abdominal brain thoracic heart Lung Condition chronic obstructive pulmonary disease (COPD) emphysema Heart cardiomyopathy chest pain or angina prescribed and/or used any form of nitroglycerin (spray, patch, pill) heart attack heart transplant cardiac or heart surgery Stroke / TIA stroke Muscle / Skeletal arthritis rheumatoid arthritis type 1 diabetes (insulin) type 2 diabetes (oral medication) chronic kidney failure diabetic neuropathy skin infection (in last 30 days) atherosclerosis angina phlebitis (vein inflammation) peripheral vascular disease (PVD) deep vein thrombosis (DVT) thrombophlebitis asthma no medication prednisone inhaler bronchitis 3 or more episodes in last 24 months What type of surgery? balloon angioplasty stent angioplasty coronary artery bypass graft How many arteries were grafted? or more bypass operations heart valve problem heart valve surgery balloon valvuloplasty stent valvuloplasty valve replacement require any assistance with activities of daily living transient ischemic attack (TIA) or mini-stroke endarterectomy (surgery on your carotid arteries) osteoporosis, osteopenia degenerative disc disease (DDD) fibromyalgia herniated disc, spinal stenosis lung infection (in last 30 days) diabetic retinopathy varicose veins surgery? YES tuberculosis pulmonary fibrosis use of home oxygen lung transplant irregular heart beat or rate (arrhythmia, bradycardia, tachycardia, atrial fibrillation, palpitations) on medication pacemaker inserted external defibrillator internal defibrillator ablation heart murmur congestive heart failure coronary artery disease prescribed blood thinner (for example Warfarin, Coumadin) before stroke after stroke sciatica scoliosis spondylosis Please continue to the next page to tell us about symptoms, investigations and treatments. Page 3 of 5
4 Stomach or bowel (intestine or colon) condition (including gallbladder, hernia, throat and liver) Gallbladder gallbladder attack gallstones gallbladder removed Bowel/intestine or colon celiac disease inflammatory bowel disease (Crohn s disease, ulcerative colitis) diverticulosis diverticulitis undiagnosed intestinal or rectal bleeding (not including hemorrhoids) irritable bowel syndrome (IBS) Stomach gastric bypass surgery GERD, acid reflux or heartburn gastritis h. pylori hernia repaired? YES ulcer repaired? YES Liver liver disease hepatitis A B C cirrhosis of the liver liver transplant Throat scleroderma, dysphagia, incoordination or achalasia Other Kidney or urinary condition kidney failure kidney dialysis Cancer Location: brain breast bone bowel, colon, intestine Hodgkin s lymphoma kidney leukemia liver lung kidney transplant 2 or more urinary infections in last 12 months protein in urine kidney cysts ovarian / cervical prostate bladder skin stomach throat cancer has spread to organs of the body inoperable in remission eliminated kidney / bladder stones How many times have you had stones? 1 2+ under treatment chemapy radiation treatment hormone replacement treatment surgery watchful waiting treatment is pending treatment declined Uterine fibroids, ovarian cysts or prostate uterine fibroid surgery YES hysterectomy ovarian cyst surgery YES benign prostatic hypertrophy (BPH) on medication surgery Nervous system conditions anxiety / emotional disorder Parkinson s disease Guillain-Barre syndrome epilepsy or seizures Alzheimer s disease travelling alone? YES require any assistance with activities of daily living? YES migraines Pregnancy If you are female, are you currently pregnant? YES If yes, what is your expected delivery date? (MM/DD/YYYY) Page 4 of 5
5 Please tell us about the history of ALL your medical conditions you checked on page 2 and 3. We need to know about your symptoms, any investigations, treatments and prescriptions you ve had. Attach a separate sheet if necessary. Medical condition Medication Date prescribed MM/DD/YYYY Last dosage change MM/DD/YYYY Symptoms/investigation/treatment and date Declaration You declare that: The information you ve provided in this questionnaire is truthful, complete and accurate. You understand that: This questionnaire and the answers you provided are part of a contract provided through AZGA Service Canada Inc. o/a Allianz Global Assistance. If your medical status or any of your answers changes between the date you complete this questionnaire and your departure date or the effective date of any extension, you must contact Allianz Global Assistance prior to leaving on your trip to fully understand how your change in health affects the underwriting decision. Failure to do so may limit the amount of your claim payment or result in your claim being denied. The underwriting decision applies regardless of the sales medium and/or channel through which you purchase insurance. If a policy is issued to you that does not include this underwriting decision, it will be considered null and void, any premiums paid will be refunded and no claims will be payable. Allianz Global Assistance will collect, use and/or disclose your personal information only to provide you with the insurance products and services you ve requested, for uses authorized by you, or as required by law. You acknowledge that: If you misrepresent your medical status in this questionnaire, or if you don t disclose material information about your medical status, or if any of your answers are found to be incorrect or untrue, your coverage will be null and void, your claims won t be paid and your premium will be refunded, even if the material non-disclosure or inaccuracy is not related to the claim reported, and you will be solely responsible for all expenses related to your claim. This coverage is subject to exclusions, terms, conditions and limitations that may limit or exclude an amount payable. Authorization You authorize: Any organization or person that has records or knowledge of your health to give any and all information regarding your health, medical history and treatment to Allianz Global Assistance or its authorized representatives. You understand and agree that: If you refuse or withdraw this authorization your application will be denied. A copy of this authorization and declaration is as valid as the original. I HAVE READ AND UNDERSTOOD THE IMPORTANT INFORMATION IN THE STATEMENT ABOVE YES You must sign and date this questionnaire or it will be returned to you. Applicant s name Signature Signature date (MM/DD/YYYY) Page 5 of 5
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
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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
PATIENT INFORMATION. Are we currently seeing one of your family members at our practice, or have we previously? YES patient s name:
PATIENT INFORMATION Date Name Address First Middle Last City State Zip Home # Cell # Check this box to authorize text messaging for confirming and reminders Email Check this box to authorize our office
BARIATRIC SURGERY PROGRAM APPLICATION Updated: 7/22/2016 Page 1 of 9
Updated: 7/22/2016 Page 1 of 9 Date: SELF Last Name: First: MI: Maiden: Address: City: State: Zip: Home #: Cell #: Work #: Date of Birth: SSN#: Gender: Male Female Marital Status: Married Divorced Widowed
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: If YES, please list medication allergies: Do you have
Urology Center, P.C.
PATIENT INFORMATION Patient Name: Male Female Address: Home Phone: Work Phone: Cell Phone: Date of Birth: Social Security Number: Referring Dr: Family Dr: Spouse/Parent: PERMISSION TO RELEASE INFORMATION
Patient Last Name First Name Middle Name. Home Address City State Zip. Date of Birth Age Social Security # - - Cell Phone Home Phone Work Phone
Date Patient Last Name First Name Middle Name Gender (circle): Male Female Other: Marital Status (circle): Single Married Divorced Widowed Separated Home Address City State Zip Date of Birth Age Social
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
\ NSMI. The National Sports Medicine InstJtute
~ \ NSMI The National Sports Medicine InstJtute 19455 Deerfield Avenue Su ite 3 12 Lansdowne, Virgin ia 20 I76 24430 Stone Spring Blvd, Suite 250, Dulles, Virginia 20166 Patient Information: Last Name:
Laser Vein Center Thomas Wright MD Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Insurance Information Primary Insurance ID# Group# Subscriber
New Patient Questionnaire
New Patient Questionnaire Name: Primary Care Physician: Date of Birth: / / Home Phone: ( ) Cell Phone: ( ) Why are you seeing a cardiologist? (please answer in detail) Have you ever seen a cardiologist
Title: Dr/Mr/Mrs/Ms/Miss Last First M.I. Circle one. Primary Address: Street # Street name Apt# City State Zip
Elissa S. Norton, MD 5162 Linton Blvd, Suite 203 P: (561) 877-3376 F: (877) 992-1153 info@brilliantdermatology.com Name: Title: Dr/Mr/Mrs/Ms/Miss Last First M.I. Circle one Primary Address: Street # Street
Adult Health History for New Patient
Adult Health History for New Patient Name: Birth Date: Today s Date: Preferred Pharmacy (name and location): Your answers on this form will help your health care provider get an accurate history of your
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Visit My Doctor Online at kp.org/mydoctor. Prepare for your visit This form will help you prepare for your upcoming visit with your doctor. You can complete it on your computer (Mac or PC) and e-mail it
TERM & UNIVERSAL LIFE GUIDELINES
DISEASE Aids HIV ALS Lou Gehrigs Disease Aneurysm Cancer Diabetes Hepatitis Kidney Failure Home Easy Term Easy U.L. Safe Shield Strong Smart U.L. Term last 7 treated in last 7 Diagonosed prior to 35 or