Healthcare Insurability Statement

Healthcare Insurability Statement

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Medical History (brief)

Statement of Insurability Questions

1. Has the patient had any medical advice, diagnosis, treatment, testing or hospitalization for the same condition within the past 12 months? Yes No

2. Has the patient been diagnosed with or treated for any heart, lung, kidney, liver, cancer, diabetes, or immune disorder? Yes No

3. Within the past five years, has the patient undergone any surgery or been advised to undergo surgery that has not yet been performed? Yes No

4. Has the patient used tobacco, nicotine products, or e-cigarettes within the last 12 months? Yes No

5. Has any health insurer declined, postponed, cancelled, or modified coverage for the patient within the past 7 years? Yes No

6. Is the patient currently pregnant or undergoing fertility treatment? Yes No

7. Is there any pending claim, investigation, or scheduled medical procedure that may affect insurability? Yes No

Authorization, Certification and Acknowledgment

I certify that the statements made in this Healthcare Insurability Statement are true, complete, and correctly set forth to the best of my knowledge. I understand that any material misrepresentation or omission may be grounds for denial of coverage or rescission of any insurance issued based on this statement and may subject me to civil or criminal penalties under applicable law.

I authorize any health care provider, health plan, insurer, employer, or other entity that has records or knowledge of me or my health to release to the requesting insurer, its representatives or designees, any medical, billing, claims, or other information necessary to evaluate insurability or to process claims. This authorization includes, but is not limited to, records regarding mental health, substance abuse treatment, HIV/AIDS testing and treatment, and genetic testing when applicable under law.

I understand this authorization will remain in effect until the earlier of the date specified below as the authorization expiration date or revocation in writing by me, except to the extent information has already been disclosed in reliance on this authorization.

By signing below I acknowledge receipt of the statements above and confirm I have read and understand the contents of this Healthcare Insurability Statement. I certify that I am the patient or the patient’s legally authorized representative and that I have the authority to execute this document on the patient’s behalf.

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