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GROUP INSURANCE The Prudential Insurance Company of America Mail the completed form to Employer/Association Name Group Medical Underwriting P. O. Box 8796 Philadelphia PA 19176 Group Contract No* s Branch No* 0 00 0 01 Or fax the completed form to 877-605-6671 Short Form Health Statement Questionnaire A separate form must be completed for each person requiring Evidence of Insurability Employee/Member Information First Name MI Last Name Number and Street P. O. Box / Apt. Number City State...
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How to fill out short form health statement
How to fill out Short Form Health Statement Questionnaire
01
Start with basic personal information: name, date of birth, and contact details.
02
Read each question carefully to understand what information is being requested.
03
Provide accurate answers regarding your medical history, including any pre-existing conditions.
04
Include details about any medications you are currently taking.
05
Answer questions about your family's medical history if prompted.
06
Review your answers for completeness and accuracy.
07
Sign and date the form to confirm that the information is true to the best of your knowledge.
Who needs Short Form Health Statement Questionnaire?
01
Individuals applying for health insurance.
02
People seeking a medical exam for employment or travel.
03
Patients undergoing a pre-evaluation for a surgical procedure.
04
Anyone who needs to provide a health summary for specific applications.
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What is Short Form Health Statement Questionnaire?
The Short Form Health Statement Questionnaire is a document used to collect basic health information from individuals, typically for insurance purposes or medical evaluations.
Who is required to file Short Form Health Statement Questionnaire?
Individuals applying for certain types of insurance policies or benefits may be required to file the Short Form Health Statement Questionnaire to provide necessary health details.
How to fill out Short Form Health Statement Questionnaire?
To fill out the Short Form Health Statement Questionnaire, individuals should carefully read the instructions, provide accurate personal health information, and ensure all required fields are completed before submission.
What is the purpose of Short Form Health Statement Questionnaire?
The purpose of the Short Form Health Statement Questionnaire is to assess an individual's health status to determine eligibility for insurance coverage and to evaluate potential risks.
What information must be reported on Short Form Health Statement Questionnaire?
Information that must be reported typically includes personal health history, current medications, any pre-existing health conditions, and family health history.
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