Get the free Short Form Health Statement Questionnaire

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...

How to fill out short form health statement

How to fill out Short Form Health Statement Questionnaire

1. Obtain the Short Form Health Statement Questionnaire from your healthcare provider or the relevant institution.
2. Read the instructions carefully to understand the purpose of the questionnaire.
3. Fill in your personal information such as name, date of birth, and contact details as requested.
4. Answer all health-related questions honestly, including your medical history, current medications, and any allergies.
5. Provide additional information if prompted, particularly if you have any chronic illnesses or conditions.
6. Review your answers for accuracy before submitting the questionnaire.
7. Sign and date the form if required, then submit it to the designated healthcare provider or institution.

Who needs Short Form Health Statement Questionnaire?

1. Individuals applying for a new health insurance plan.
2. Patients preparing for surgery or medical procedures.
3. Participants in clinical trials or medical research studies.
4. Clients seeking services from health or wellness programs.
5. Anyone needing a health assessment for a specific purpose, such as a visa or travel.

For pdfFiller’s FAQs

What is Short Form Health Statement Questionnaire?

The Short Form Health Statement Questionnaire is a concise document used to gather information about an individual's health status, typically for insurance or medical purposes.

Who is required to file Short Form Health Statement Questionnaire?

Individuals seeking health insurance or those who need to provide health information for specific purposes such as underwriting are typically required to file the Short Form Health Statement Questionnaire.

How to fill out Short Form Health Statement Questionnaire?

To fill out the Short Form Health Statement Questionnaire, individuals should provide accurate personal health information as requested, answering all questions clearly and completely.

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 risks and determine eligibility for insurance coverage or benefits.

What information must be reported on Short Form Health Statement Questionnaire?

The information that must be reported typically includes personal health history, existing medical conditions, medications being taken, and any previous medical treatments or surgeries.