CFG: Dignified Choice AGE 25-85
|
|
|
- Charleen Hill
- 5 years ago
- Views:
Transcription
1 DISESE/DISORDER N/ = Not pplicable for this product = Phone Interview required Foresters: Living Promise GE CFG: Dignified Choice GE impairment Transmerica: GE decisions Oxford: ssurance Phoenix Life GE IDS lcoholism Diagnosed, treated, or advised to receive treatment within past 2 years: Diagnosed, treated, or advised to receive treatment within past 2 years: Last 36 months: diagnosed, treated, or advised to seek treatment: 2 years: Diagnosed, treated, or advised to receive treatment, or excessively used alcohol within past 5 years: 5 or more years since treatment: CCEPT Current: lzheimer s *ricept, Cognex, Denepezil, Exelon, Razadyne, Namenda* (UTO ) CLSSIC SECURITY taken medication for: mputation CCEPT Complications from diabetes: Injury: CCEPT Disease, including diabetes, Quadri/Paraplegia: Due to disease: Due to disease: Due to disease within the past 2 years OR current paralysis of two or more extremities: Injury: CCEPT Due to disease within past 1 year: neurysm Within 2 years of diagnosis or if it has been removed: treatment: Last 24 months: to seek treatment: 2 years: Within the past 24 months: taken medication for: ngina (Chest Pain) Within 2 years: treatment: Last 24 months: to seek treatment: 2 years: Standard medication for: taken medication for: 1
2 DISESE/DISORDER N/ = Not pplicable for this product = Phone Interview required Foresters: Living Promise GE CFG: Dignified Choice GE impairment Transmerica: GE decisions Oxford: ssurance Phoenix Life GE ngioplasty/stent Implant Within 2 years: In the past 2 years, received treatment: Last 24 months: to seek treatment: 2 years: medication for: taken medication for: rrhythmia N/ *Check current medication for dual usage treatment: CLSSIC SELECT to seek treatment: 2 years: medication for: If diagnosed more than 2 years ago and current age 50 or older: CCEPT Otherwise: trial Fibrillation (-Fib) N/ *Check current medication for dual usage treatment: CLSSIC SELECT to seek treatment: 2 years: medication for: If diagnosed more than 2 years ago and current age 50 or older: CCEPT Otherwise: Bipolar Disorder N/ Bipolar Depression: (This is not the same as Depression) N/ N/ CCEPT If taking 3+ medications or hospitalization in past 2 years: Bronchitis Chronic: Chronic (Including Lung Disease, COPD, Emphysema or Sarcoidosis): Chronic: advised to seek treatment: medication for: CCEPT 2
3 DISESE/DISORDER N/ = Not pplicable for this product = Phone Interview required Foresters: Living Promise GE CFG: Dignified Choice GE impairment Transmerica: GE decisions Oxford: ssurance Phoenix Life GE Bypass Surgery (CBG) care or advised to seek treatment: care or advised to seek treatment: Last 24 months: treated or advised to seek treatment: 2 years: medication for: taken medication for: Cancer Basal Cell: CCEPT If diagnosis, or received treatment within past 3 years: Currently has cancer, or had one or more reoccurrences, or had more than one type of cancer: Basal or Squamous cell: CCEPT In the past 4 years - received treatment: Metastatic, or currently being treated for cancer: Last 24 months: CLSSIC SECURITY Last months: CLSSIC SELECT (Basal Cell not included) Diagnosed, treated for, or advised to seek treatment within the past 4 years: or reoccurrence of cancer, or any metastasis of any cancer (excluding Basal or Squamous Cell): Diagnosis and end of treatment over 5 years ago: CCEPT Otherwise: Cardiomyopathy Had or diagnosed in past 2 years: treatment: CLSSIC SELECT to seek treatment: Past 2 years: taken medication for: Circulatory Surgery (Including bypass, angioplasty) Treatment advised or received in past 2 years: Treatment advised or received in past 2 years: Treatment advised or received in past 2 years: treated, advised, or received: 2 years: medication for: Treatment advised or received, or taken medication for: 3
4 DISESE/DISORDER N/ = Not pplicable for this product = Phone Interview required Foresters: Living Promise GE CFG: Dignified Choice GE impairment Transmerica: GE decisions Oxford: ssurance Phoenix Life GE Cirrhosis of Liver Last 36 months: to seek treatment: 2 years: medication for: COPD (Chronic Obstructive Pulmonary Disease) Including Chronic Bronchitis or Emphysema: Including chronic Bronchitis or Emphysema: advised to seek treatment: medication for: CCEPT *Possible reasons for decline includes current tobacco use, or within past 12 months, current oxygen use or chronic oral steroids required CHF (Congestive Heart Failure) CLSSIC SECURITY to seek treatment: 2 years: Dementia CLSSIC SECURITY Diabetes CCEPT Coma in past 2 years: Diabetic Nephropathy/ Retinopathy or Neuropathy in past 2 years: CCEPT If ever received treatment or advised to receive treatment for diabetes before age 50, or diabetes at any age with complications of retinopathy, nephropathy, or neuropathy: Complications, insulin use before age 50, coma, or not under control in the past 36 months: Diagnosed before the age of 18 (other than gestational): Diagnosed prior to age 30 or ever had any complications such as insulin shock, retinopathy, or diabetic neuropathy: Type 1 or 2: POSSIBLE CCENT Under age 30: 4
5 DISESE/DISORDER N/ = Not pplicable for this product = Phone Interview required Foresters: Living Promise GE CFG: Dignified Choice GE impairment Transmerica: GE decisions Oxford: ssurance Phoenix Life GE Driving Record (Including D.U.I.) dvised to receive treatment for alcohol or drug abuse as a result of a D.U.I. or driving violation: In the past 2 years - convicted more than once of reckless driving, felony or D.U.I.: Three or more moving violations within past 36 months: N/ Within the last 5 years: Driver s license suspended or revoked or any D.U.I. violations within the past 3 years: Drug buse/ddiction Diagnosed, treated, or advised to receive treatment within past 2 years: In the past 2 years - used unlawful drugs or misused/ abused prescription drugs: Last 36 months: Used illegal drugs within the past 1 year or diagnosed, treated, or advised to seek treatment: 2 years: Within the last 5 years: 5 or more years since treatment: CCEPT Current or within the past 5 years: Felony (Probation & Parole) Confined to a correctional facility: Felony in the past 2 years: Pled guilty to any crime: N/ Within the last 10 years: Felony in the past 5 years: Gastric Bypass Had or diagnosed within 2 years: treatment: *Rate Build Last 24 months: to seek treatment: 2 years: medication for: Surgery more than 6 months ago without complications: USULLY CCEPT Heart ttack Had or diagnosed within past 2 years: treatment: Last 6 months: CLSSIC SECURITY Within 7-24 months: to seek treatment: 2 years: medication for: taken medication for: 5
6 DISESE/DISORDER N/ = Not pplicable for this product = Phone Interview required Foresters: Living Promise GE CFG: Dignified Choice GE impairment Transmerica: GE decisions Oxford: ssurance Phoenix Life GE Heart Murmur Had or diagnosed within past 2 years: N/ CLSSIC SELECT to seek treatment: 2 years: medication for: CCEPT Heart Surgery Had or diagnosed within 2 years: More than 24 months: POSSIBLE LEVEL months: Within the past 12 months: Last 24 months: to seek treatment: 2 years: medication for: taken medication for: Hepatitis Chronic: Hepatitis C: Chronic within the last 36 months: to seek treatment: 2 years: medication for: Hepatitis and fully recovered: CCEPT Hepatitis B & C: HIV + VE Tested positive: Hospitalization Current or Question 3 Yes : Current: Current: Current: Current: Current: 6
7 DISESE/DISORDER N/ = Not pplicable for this product = Phone Interview required Foresters: Living Promise GE CFG: Dignified Choice GE impairment Transmerica: GE decisions Oxford: ssurance Phoenix Life GE Kidney Disease/Failure/Dialysis Kidney Disease: Dialysis within past 12 months: Last 36 months: received dialysis, diagnosed, treated or advised to seek treatment for kidney failure due to disease: Within the past 4 years - had, diagnosed with, treated or advised to seek treatment for kidney disease: Leukemia Last 24 months: CLSSIC SECURITY Last months: CLSSIC SELECT Diagnosed with, treated, or advised to seek treatment within the past 4 years (other than Basal Cell): medication for: Lupus Within the past 4 years - received care or advised to seek treatment for Systemic Lupus: Systemic Lupus within the last 36 months: N/ medication for: Lupus (Discoid): CCEPT Systemic: Liver Disease/Transplant Transplant: Disease within last 36 months: diagnosed, treated, or advised to seek treatment: medication for: If ever diagnosed, treated, or taken medication for: Marijuana Tobacco Rate Illegal drug use or treatment within the past 2 years: Tobacco Rate Used within the past 1 year: 2 years: Tobacco Rate CCEPT Possible tobacco rates 7
8 DISESE/DISORDER N/ = Not pplicable for this product = Phone Interview required Foresters: Living Promise GE CFG: Dignified Choice GE impairment Transmerica: GE decisions Oxford: ssurance Phoenix Life GE Multiple Sclerosis (MS) *Check current medication use/mix *Check wheelchair use or DL assistance In the past 4 years - received treatment: Last 36 months: advised to seek treatment: medication for: If ever diagnosed, treated, or taken medication for: Muscular Dystrophy (MD) *Check current medication use/ mix *Check wheelchair use or DL assistance CLSSIC SECURITY treated or advised to seek treatment for MD: medication for: If ever diagnosed, treated, or taken medication for: Oxygen Use (excluding Sleep pnea) Within past 12 months: Current use only: Within the past 1 year: Current use or within the past 24 months: Pacemaker Had or diagnosed within past 2 years: In the past 2 years - received care, or advised to seek treatment: Last 24 months: to seek treatment: 2 years: medication for: If ever diagnosed, treated, or taken medication for: Paralysis If any ctivities of Daily Living (DL) are impacted OR wheelchair use: Includes Paraplegia or Quadriplegia: Kidney complications or DL assistance: Confined to a wheelchair due to disease: Wheelchair use within the past 2 years: If ever - Two or more extremities: Includes Paraplegia or Quadriplegia: Parkinson s Disease If able to perform all DLs: Otherwise: Last 36 months: advised to seek treatment: medication for: 8
9 DISESE/DISORDER N/ = Not pplicable for this product = Phone Interview required Foresters: Living Promise GE CFG: Dignified Choice GE impairment Transmerica: GE decisions Oxford: ssurance Phoenix Life GE Peripheral Vascular Disease (PVD) *Check medications (especially blood thinners and first fill date) and LL heart questions: LEVEL If ever received care or advised to receive treatment for PVD or PD: Last 36 months: to seek treatment: 2 years: medication for: CCEPT If surgically corrected and/or in multiple limbs, or tobacco use: Pulmonary Embolism *Check medications (especially blood thinners and first fill date) and LL heart questions: LEVEL In the past 2 years - received care, or advised to seek treatment: Within the past 24 months: to seek treatment: 2 years: medication for: Two or fewer episodes, fully recovered: CCEPT Otherwise: Sarcoidosis *Decision based on current medication use within the past 2 years If ever received care or advised to receive treatment: Last 36 months: advised to seek treatment: medication for: Mild (stage 0-1, asymptomatic): CCEPT Moderate to Severe: 9
10 DISESE/DISORDER N/ = Not pplicable for this product = Phone Interview required Foresters: Living Promise GE CFG: Dignified Choice GE impairment Transmerica: GE decisions Oxford: ssurance Phoenix Life GE Schizophrenia No medication for Dementia, must be able to complete aptical and legal capacity to make their own decisions: LEVEL In the past 4 years - received treatment: Last 36 months: N/ Seizures LEVEL N/ N/ had more than 12 seizures: 2 years: N/ CCEPT Diagnosed within the past year, severe, or hospitalized within past 2 years: Stroke/CV/TI Had or diagnosed within past 2 years: treatment: Last 24 months: to seek treatment: 2 years: medication for: Terminal Illness or End-stage Transportation ssistance If any DLs are impacted OR wheelchair use: Wheelchair or scooter (other than for fractures, bone or joint injury or replacement): Confined to a wheelchair: Wheelchair use within the past 2 years: Within the past 5 years - If any DLs are impacted OR wheelchair use: If any DLs are impacted OR wheelchair use: Weight SEE BUILD CHRT SEE BUILD CHRT SEE BUILD CHRT N/ SEE BUILD CHRT SEE BUILD CHRT 10
11 BUILD CHRTS - GENDER NEUTRL (Outside these ranges use E.I.W.L) Height FORESTERS PlanRight - Level FORESTERS Graded FORESTERS Modified Mutual of Omaha Living Promise Level Mutual of Omaha Living Promise Graded OXFORD 4 8" "
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
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
*********Americo, Foresters and CFG include medication use in decline timeframe*********
*********Americo, Foresters and CFG include medication use in decline timeframe********* Conditions Americo Ultra Protector Americo Eagle Premier Mutual of Omaha Living Promise Transamerica 45-85 Foresters
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
FINALEXPENSEDOJO.COM
HEALTH CHEAT SHEET MOST COMMON CONDITIONS ALWAYS GI OXYGEN, AIDS/HIV, DEMENTIA/ALZHEIMER'S LUNG/BREATHING PROBLEMS ~COPD - LBL (STD) ~CHRONIC ASTHMA - AMERICO EAGLE LEVEL DIABETES ~PILLS & INSULIN - AMERICO
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
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
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
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,
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
Simplified Issue Underwriting and Medical Impairment Guide
Underwriting Guide UNDERWRITING GUIDE Simplified Issue Underwriting and Medical Impairment Guide SagicorLifeUSA.com Table of Contents 3 Simplified Issue Application Submission Process 3 Our Simplified
Welcome to the Healthplex!
Welcome to the Healthplex! Program Please check program that applies to you. If unsure, please ask our staff. Aftercare Employee Health Pulmonary Rehab Lung Gym Cardiac Rehab Health Improvement Prenatal/Post-Partum
Quote Request. Advisor Information. Client Information. Medical History. Driving History. Advisor Company Date. Phone Fax.
Advisor Information Advisor Company Date E-Mail Phone Fax Client Information Client Name Date of Birth Occupation Plan and amount of insurance requested: Has the case been submitted to other companies
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
Southwest Service Life Insurance Company
Southwest Service Life Insurance Company UNDERWRITING GUIDE 2/2012 95587v1Proof.indd 1 95587v1Proof.indd 2 95587v1Proof.indd 3 Acne A A A ADD A A A Addison s Disease D A D AIDS, ARC, HIV Infection D D
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
Anesthesia Preoperative Patient History
Anesthesia Preoperative Patient History Please Complete and BRING WITH YOU to Your Anesthesia Appointment Patient Name: Date of Birth: Phone Number: Kind of Surgery You are Having: Date of Your Surgery:
Underwriting Guidelines. for Total Living Coverage
Underwriting Guidelines for Total Living Coverage Underwriting Guidelines Pre-Qualifying Questions Underwriting Conditions Underwriting Classes Underwriting Life Rates Preferred Life Criteria Preferred
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)
Highland Colony Dental- Donald K. Givan, DMD
Highland Colony Dental- Donald K. Givan, DMD ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRAcTICES *You May Refuse to Sign This Acknowledgement* I, have received a copy of this office s Notice of Privacy
ACOFP 55th Annual Convention & Scientific Seminars. How Complicated is Your Panel? Effective Risk Coding in Primary Care. Alison Mancuso, DO, FACOFP
8 ACOFP 55th Annual Convention & Scientific Seminars How Complicated is Your Panel? Effective Risk Coding in Primary Care Alison Mancuso, DO, FACOFP How Complicated is Your Panel?: Effective Risk Coding
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
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
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)
ALF Boss's ALF Cheat Sheet For ADRC's Phone Interview For Long Term Care
DIRECTONS: Answer the following questions to help prepare for the ADRC phone interview. The more details you can provide regarding the resident's care and health needs the better. Resident Name: 01. How
PATIENT REGISTRATION
PATIENT REGISTRATION Patient Information Whom may we thank for referring you to our office? _ Date Preferred Name (Circle) Patient Name Age Birthdate M or F First M.I. Last Residence & Mailing Address
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
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
PLEASE FILL OUT THIS FORM COMPLETELY. SUBMIT TO THE ABOVE ADDRESS WE WILL CONTACT YOU FOR AN APPOINTMENT
Date: Bariatric Services Digestive Health Center Oregon Health & Science University 3303 SW Bond Avenue CHH6D Portland, OR. 97239 Phone: (503) 494-1983 Fax: (503) 418-3683 Email: w8reduce@ohsu.edu www.ohsuhealth.com/surgicalweightreduction
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
HEALTH HISTORY Since your well-being is our primary concern, please take the time to accurately answer the questions.
HEALTH HISTORY Since your well-being is our primary concern, please take the time to accurately answer the questions. Date: Patient Full Name: DOB: Sex: M / F Social Security #: Address: Home #: Cell #:
RAJIV SOOD MD, FACS AESTHETIC AND RECONSTRUCTIVE PLASTIC SURGERY MEDICAL HISTORY Today s Date: Name Date of Birth
RAJIV SOOD MD, FACS AESTHETIC AND RECONSTRUCTIVE PLASTIC SURGERY MEDICAL HISTORY 317-880-6825 Today s Date: Date of Birth Phone # Alternate # Age Height Current weight Significant other Name: Reason for
Patient Name: Date: Address City State Zip Code. H. Phone W. Phone Cell Phone
Patient Name: Date: Address City State Zip Code H. Phone W. Phone Cell Phone Email Address: Sex M F Marital Status M S D W Date of Birth Age SS# Occupation Employer Referred by: Have you ever received
The Muscatine Study Heart Health Survey
The Muscatine Study Heart Health Survey PARTICIPANT ID LABEL (include study ID, name, DOB, gender) Today s Date: - - (MM-DD-YYYY) Thank you for agreeing to participate in the International Childhood Cardiovascular
Opioid Treatment Center Application
PLEASE FILL OUT ALL AREAS COMPLETLY Name: Date: Maiden Name or Aliases: Address: Phone: Date of Birth: SSN#: Gender: Male Female Referral Source: Phone #: Annual Family Income: SSDI SSI Other Income Insurance
Underwritten by Genworth Life Insurance Company and in New York by Genworth Life Insurance Company of New York Administrative Offices: Richmond, VA
L O N G T E R M C A R E I N S U R A N C E U N D E R W R I T I N G G U I D E Underwritten by Genworth Life Insurance Company and in New York by Genworth Life Insurance Company of New York Administrative
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
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM PATIENT NAME: DATE OF BIRTH: TVA Physician being seen: Date of Visit: PAST MEDICAL HISTORY HEART PROBLEMS NEUROLOGICAL Congestive Heart Failure
Patient Name: Address City State Zip Code. H. Phone W. Phone Cell Phone. Do you want statements ed? Y/N
Address City State Zip Code H. Phone W. Phone Cell Phone Would you like text apt. Reminders? Y/N If yes Cell Carrier Email address Do you want statements emailed? Y/N Sex M F Marital Status M S D W Emergency
Face Amount Max Premium $ /yr. UL WL Term Survivorship
Please answer all questions applicable to the client s medical history. Producer Name Phone Fax Client Name of Birth Male Female Face Amount Max Premium $ /yr. UL WL Term Survivorship Does the client currently
TrueView Underwriting SM. Guide. Underwriting Guide I Long Term Care Insurance
I Long Term Care Insurance SM Grid Underwritten by Genworth Life Insurance Company and in New York by Genworth Life Insurance Company of New York Administrative Office: Richmond, VA 143345i 03/15/16 1
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)
Form OS Follow-Up Questionnaire (Observational Study - Year 4) Ver. 1.1 Page 1
Form 144 - OS Follow-Up Questionnaire (Observational Study - Year 4) Ver. 1.1 Page 1 FORM: 144 - OS FOLLOW-UP QUESTIONNAIRE (Observational Study - Year 4) Version: 1.1 July 15, 1998 Description: When used:
Patient s name Patient s phone numbers Emergency contact name Emergency contact phone number Relationship to patient
Advocate Condell Wound Healing Center 801 South Milwaukee Ave, West Tower Libertyville, IL 60048 847-990-5670 Patient s name Patient s phone numbers Emergency contact name Emergency contact phone number
ADVANCED SPINE HEALTH AND WELLNESS CENTER DR. PAUL BACON
ADVANCED SPINE HEALTH AND WELLNESS CENTER DR. PAUL BACON Patient Name: Address: City: State: Zip Code: H. Phone: W. Phone: Cell Phone: Email Address: Sex M F Marital Status M S D W Date of Birth Age Social
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:
TrueView Underwriting SM. Guide. Underwriting Guide I Long Term Care Insurance
I Long Term Care Insurance SM Grid Underwritten by Genworth Life Insurance Company and in New York by Genworth Life Insurance Company of New York Administrative Office: Richmond, VA 143345i 08/07/14 For
CHEMICAL DEPENDENCY EVALUATION INTERVIEW. A. Demographics
CHEMICAL DEPENDENCY EVALUATION INTERVIEW DATE OF EVALUATION A. Demographics COMPANY NAME: NAME ADDRESS PHONE: MARITAL STATUS SOCIAL SECURITY # DATE OF BIRTH AGE GENDER RACE/ETHNICITY VALID DRIVER S LICENSE:
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
We are an academic institution What does that mean?
DERMATOLOGY & CUTANEOUS SURGERY We are an academic institution What does that mean? USF Health is an academic institution where future healthcare providers are trained. Below is a description of the different
The Willed Body Program The University of Texas Southwestern Medical Center
The Willed Body Program The University of Texas Southwestern Medical Center Medical History and Research Assessment Questionnaire SAB ID Donor Name: _ Person completing form: Relationship to donor: te:
NEW PATIENT INFORMATION RECORD PATIENT INFORMATION
Zumbro Vein Institute NEW PATIENT INFORMATION RECORD PATIENT INFORMATION 501 Blackburn Drive Martinez, GA 30907 706-854-8340 Fax: 706-854-8341 www.veinsaugusta.com First Name: Last Name: MI: Social Security
LTSR CRITERIA CHECKLIST (PLEASE PRINT LEGIBLY)
LTSR CRITERIA CHECKLIST (PLEASE PRINT LEGIBLY) Consumer s Name: Date: Person Completing Referral: Agency: Phone: Ext: Email: 18 years or older Crossroads LTSR 337 Tippecanoe Road Smock Pa, 15480 Phone:
(Title) First Name MI Last Name Maiden Name Suffix. What do you prefer to be called?
516 South Division Street, Suite 105 Cedar Falls, IA 50613-2381 Tel 319.268.3990 Fax 319.268.3995 Patient Demographic Information: Date (Title) First Name MI Last Name Maiden Name Suffix What do you prefer
MEDICAL/SURGICAL HISTORY FORM
MEDICAL/SURGICAL HISTORY FORM / / Date: / / Surgical Patients Only: Please check the weight loss procedure that you are interested in: Gastric Bypass Lap Band Undecided Revision of Previous Surgery HT
Patient Information. Patient Name: DOB: Last First M.I. Home Address: City: State: Zip: Home Phn: Cell Phn: Alt. Phn: SSN:
Dr. Alvin Huang, M.D., F.A.C.E. 1650 W. Rosedale St. Suite 301, Fort Worth TX 76104 (P) 817-259-4333 (F) 817-820-0303 Patient Information Patient Name: DOB: Last First M.I. Home Address: City:_ State:
Program Application for:
Prince of Peace Center P. O. Box 89 502 Darr Ave. Farrell, PA 16121 724-346-5777 www.princeofpeacecenter.org Program Application for: 1 Referred by HOPE FAITH Head of Household Information Gender Male
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,
Patient Health History
Patient Health History This information is very important in your care. Please complete as carefully and accurately as possible. Name: Date: Height: inches Weight: lbs Age: Symptoms: 1. Type of symptoms
Patient information. Today s Date. Patient s Name D.O.B. Street Address Apt. No. Home Phone # Work Phone # Social Security # DL # State
Patient information Today s Date Patient s Name D.O.B Street Address Apt. No. City / State / Zip Code Home Phone # Work Phone # Social Security # DL # State Sex Female Male Marital Status Single Married
Hear land Men s Recovery Center
Hear land Men s Recovery Center Page 1 of 6 Please read and follow these important guidelines: 1. Complete the 5-page application. Mail or fax it back to us at the address or number above, along with copies
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:
Guiding Eyes for the Blind 611 Granite Springs Road, Yorktown Heights, New York PHONE FAX
Guiding Eyes for the Blind 611 Granite Springs Road, Yorktown Heights, New York 10598 PHONE 914 243-2216 admissions@guidingeyes.org FAX 914 243-2232 PHYSICIAN S REPORT Patient s Name: Date of Birth: Physician
Medical Declaration Form. Important information to read before completing the form:
Administered by Medical Declaration Form Important information to read before completing the form: Pre-Existing Medical conditions Travel insurance only provides cover for emergency medical events that
CHEMICAL USE EVALUATION INTERVIEW. A. Demographics
CHEMICAL USE EVALUATION INTERVIEW DATE OF EVALUATION A. Demographics COMPANY NAME: NAME ADDRESS PHONE: MARITAL STATUS SOCIAL SECURITY # DATE OF BIRTH AGE GENDER RACE/ETHNICITY VALID DRIVER S LICENSE: YES:
ITG Diet Health Status Intake Form
Health Status Intake Form Date: Last Name: First Name: D.O.B: Address: City: ST: ZIP Phone: Cell: Email: Age: HT: WT: BMI: Fat %: Occupation: Sex: M F Marital Status: M S D W How did you hear about the
PATIENT DEMOGRAPHIC INFORMATION
PATIENT DEMOGRAPHIC INFORMATION Patient Name: (First, MI, Last) Sex: [ ] M [ ] F Birth Date: Age: SS#: Email: Race: Ethnicity: Language: Mailing Address: Work Ph: ( ) City: State: Zip Code: Home Ph: (
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
Face Amount Max Premium $ /yr. Term Permanent
Please answer all questions applicable to the client s medical history. Producer Name Phone Client Name of Birth Male Female Face Amount Max Premium $ /yr. Term Permanent Has the client ever used any form
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
HEALTH HISTORY Since your well-being is our primary concern, please take the time to accurately answer the questions.
HEALTH HISTORY Since your well-being is our primary concern, please take the time to accurately answer the questions. Date: Patient Full Name: DOB: Sex: M / F Social Security #: Address: Home #: Cell #:
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
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
PERSONAL HISTORY CURRENT HEALTH CONDITION
PERSONAL HISTORY Name: Date S.S.# Address: City: State Zip code Home phone Cell Other: E-Mail Date of Birth Age Sex Male Female Business/Employer Address Type of Work Years Employed Check One Married Single
This page is for information. Do not submit.
This page is for information. Do not submit. AISH Application - Part B Medical Report Information for Physicians Your patient (the applicant) is applying for the Assured Income for the Severely Handicapped
EXAM BY M.D. O yes. O ft/in O cm. O lb O kg. O yes O no. O unknown. O no 1. LIFE INSURED 2. PERSONAL INFORMATION 2.1 RELATED MEDICAL INFORMATION
EAM BY M.D. 1. LIFE INSURED Name (first, middle, last) Date of birth (dd/mmm/yy) 2. PERSONAL INFORMATION Do you have a regular physician/nurse practitioner? If yes, please provide the following (If your
Alzheimer Disease Research Center
UPMC Montefiore, 4 West 200 Lothrop Street Pittsburgh, PA 15213-2582 412-692-2700 Fax: 412-692-2710 Dear Friends: Thank you for your inquiry about the (ADRC). Attached is an application which asks for
MDGuidelines API: Case Fit v3 Specification 1.3
MDGuidelines API: Case Fit v3 Specification 1.3 Date: August 23, 2017 1 Overview 1.1 Purpose and Intended Audience The purpose of this document is to provide detailed descriptions and specifications for
New Patient Medical Questionnaire DATE:
New Patient Medical Questionnaire DATE: Patient Name: DOB: AGE: Other Physicians: Who can we thank for referring you to our practice? Pharmacy Name & Location:` Phone # CHIEF COMPLAINT What problems are
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
Name: Age: DOB: / / City Zip Wk Tel: ( ) Cell: ( ) Referring Physician: How did you hear about Dr. Ordon?
Andrew P. Ordon, M.D., F.A.C.S. 465 N. Roxbury Drive, Suite 1001, Beverly Hills, CA 90210 Tel: (310) 248-6250 w Fax: (310) 861-1529 www.drordon.com Date: Name: Age: DOB: / / Address: Home Tel: ( ) City
THE RELATIONSHIP BETWEEN ACTIVITIES OF DAILY LIVING AND MULTIMORBIDITY. A VIEW FROM TELECARE
THE RELATIONSHIP BETWEEN ACTIVITIES OF DAILY LIVING AND MULTIMORBIDITY. A VIEW FROM TELECARE Edurne Alonso Morán Biostatician Researcher Collaborative Research of Osatek, SA, Public Society of the Basque
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
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
Patient Registration. Additional Information. Insurance Information. Patient s Full Name: Date: Home Address:
Patient Registration Patient s Full Name: Home Address: Home Phone Number: Cell Phone Number: Social Security #: DOB: Relationship Status: Married Divorced Single Place of Employment: Work Address: Work
Intake Form. Date: Referred By: Name: Phone Number: Religious Affiliation: Where are you currently staying? City?
Intake Form Date: Referred By: Name: Phone Number: Email: Religious Affiliation: Where are you currently staying? City?: Birthdate: Age: Place of Birth: Citizenship: Race: Social Security Number: Marital
EMPLOYMENT APPLICATION
BOYS & GIRLS CLUBS of CENTRAL TEXAS, INC. 304 West Avenue B Killeen, TX 76541 (254) 699-5808 EMPLOYMENT APPLICATION DATE LOCATION NOTE TO ALL APPLICANTS: The Boys & Girls Clubs of Central Texas (BGCCT)
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
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
For Office Use Only: MA complete Date of Visit / / mm/dd/yyyy. This form must be scanned into the medical record. Do not remove from clinic.
For Office Use Only: MA complete Date of Visit / / mm/dd/yyyy This form must be scanned into the medical record. Do not remove from clinic. UWMC Women s Health Care Center & SCCA Women s Cancer Center
Patient Interview Form
Page 1 of 6 STEPHEN G. ABSHIRE, M.D. JAMES N. ARTERBURN, M.D. ERIC P. TRAWICK, M.D. JACOB R. KARR, M.D. SYLVIA OATS, ANP-BC SUSAN MIEDECKE, FNP-BC CINDY LANDRY, ANP-BC 1211 Coolidge Blvd. Suite 303 Lafayette,
Primary Care Clinic Adult Patient Demographics
Primary Care Clinic Adult Patient Demographics Patient s Name: Previous or Nickname: Sex: Male Female Social Security Number - - Date of Birth: Mailing Address: City State Zip Code Home Phone #: ( ) -
Emergency Contact Name Relationship Phone Primary Care Physician Phone Did a Physician Refer you to us? YES NO Physician Name
TELL US ABOUT YOU (please print) First MI Last Address 1 Address 2 CITY ST ZIP COUNTRY E-mail Opt out of providing E-mail Address Language Preference SSN - - DOB / / Driver s License # ST Phone 1 CELL
Advanced Laparoscopic Specialists Minimally Invasive and Bariatric Surgery
Advanced Laparoscopic Specialists Minimally Invasive and Bariatric Surgery Date of Visit: Health Questionnaire (Please Print) Name: _ Last First MI Date of Birth: Social Security # Driver s License #:
PATIENT INFORMATION NAME: LAST FIRST MIDDLE ADDRESS: CITY: STATE: ZIP CODE DOB: / / AGE: MARITAL STATUS: M S D W SEP
PATIENT INFORMATION DATE: SS#: NAME: LAST FIRST MIDDLE ADDRESS: CITY: STATE: ZIP CODE DOB: / / AGE: MARITAL STATUS: M S D W SEP Primary contact #: ( ) Is this: Home Cell Work Other: May we leave a detailed
If so, when: Demographic Information Male Transgender Height: Weight: Massachusetts Resident? Primary Language: Are you currently homeless?
Application Form rev. 9/09 Jeremiah's Inn P.O. Box 30035 1059 Main St., Worcester, MA 01603-0035 FAX 508.793.9568 Phone 508.755.6403 Last Name: Suffix: First Name: Middle Initial: Alias: Referral Information
Triple Crown Chiropractic Center Dr. Erik Simms D.C Clay Drive Walton, KY (859)
Triple Crown Chiropractic Center Dr. Erik Simms D.C. 11053 Clay Drive Walton, KY 41094 (859) 918-6868 Patient Name: Address: City: State: Zip Code: H. Phone: Cell Phone: Email Address: Date of Birth: May
PHYSICIAN S STATEMENT OF EXAMINATION
PHYSICIAN S STATEMENT OF EXAMINATION Michigan Department of State Driver Assessment and Appeal Division P.O. Box 30196 Lansing, Michigan 48909-7696 Phone: (517) 335-7051 Fax: (517) 335-2189 INSTRUCTIONS
Documenting in the World of ICD-10 Capturing all your CCs and MCCs Crystal Coen, RN, MSN, FNP-BC NPSS Asheville, NC
Documenting in the World of ICD-10 Capturing all your CCs and MCCs Crystal Coen, RN, MSN, FNP-BC 2017 NPSS Asheville, NC Objectives Understand the importance of documenting to the highest specificity Understand