Healthcare Pre-Underwriting Questionnaire

Healthcare Pre-Underwriting Questionnaire

Patient Information

Patient Name:

Date of Birth:    Gender:    Last 4 of SSN (optional):

Insurance and Proposed Coverage

Medical History

Family History (major illnesses in first-degree relatives):

Condition Checklist

Check any conditions that apply and provide details where requested.

Lifestyle and Risk Factors

Tobacco use in past 12 months:

Alcohol use (average per week):    Illicit drug use:

Height:    Weight:    Occupation / hazardous exposures:

Recent Medical Care

Primary care physician:

Date of last physical exam:    Date of last blood work:

Authorization for Release and Use of Medical Information

I authorize any physician, medical practitioner, hospital, clinic, pharmacy benefit manager, pharmacy, medical facility, insurer, or other provider to disclose medical records, medical information, prescription history, and other protected health information to the insurer(s), their reinsurers, representatives and administrators for the purpose of underwriting and risk classification related to this application. This authorization includes records relating to mental health, alcohol and drug use, and HIV-related conditions unless otherwise restricted by law.

I understand that the information obtained will be used solely for underwriting and risk assessment related to insurance coverage and that such information may be shared with the insurer's affiliates, reinsurers, and service providers as necessary. I acknowledge that a photocopy or electronic copy of this authorization is as valid as the original.

I understand that I may revoke this authorization at any time by delivering a written notice to the insurer, except to the extent that action has already been taken in reliance on this authorization. Unless revoked earlier, this authorization expires one year from the date signed, or upon completion of the underwriting process, whichever occurs first.

Authorization expiration date (if different):

HIPAA Acknowledgment

I acknowledge receipt of the Notice of Privacy Practices and authorize the use and disclosure of protected health information as described above for underwriting purposes. I understand that the privacy practices described in the notice apply to information created or received by the insurer in connection with this underwriting request.

Certification and Attestation

I certify that the information I have provided on this questionnaire is complete and true to the best of my knowledge. I understand that material misrepresentation or omission of facts may be grounds for denial of coverage or rescission of the policy. I consent to the release and use of information as described for the purpose of underwriting.

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