Get Medical History Statement - Short Form - Generic, 16119.pdf

Completing the Medical History Statement - Short Form - Generic, 16119.pdf online is a straightforward process that helps ensure accurate and efficient health coverage. This guide provides a step-by-step approach to help you fill out the form correctly.

Follow the steps to successfully complete the form online.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred online editor or navigation tool.
2. Provide member/employee information, including the name of the group, group number, and your personal details such as name, birth date, and occupation. This information is essential for identifying your coverage needs.
3. In the applicant information section, indicate the name of the person to be insured and provide their contact information, including email address, street address, and phone numbers. Be accurate to ensure proper communication.
4. Check the type of coverage you are applying for under the application information section. Fill in the current amounts in force, if any, and the additional amount requested for each type of coverage.
5. In the physician information section, provide the name and address of your doctor or medical facility, along with the date last consulted and the reason for the consultation.
6. Answer the medical history statement questions honestly. For each question, mark 'yes' or 'no' and provide details for any 'yes' answers, using a separate sheet if necessary to include all relevant information.
7. Fill out the acknowledgment and authorization section, verifying that your responses are accurate. This may involve initialing or signing to indicate your consent to release health information.
8. Finally, after reviewing your entries for accuracy, you can save changes, download the completed form, print it, or share it as needed.

Start completing your documents online today for a smoother process.