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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
Read the instructions carefully before starting.
02
Gather any relevant medical information that you may need to refer to.
03
Begin filling out the personal information section, including your name, date of birth, and contact details.
04
Answer the health-related questions honestly, checking relevant boxes or writing clear responses.
05
Review your answers for completeness and accuracy.
06
Sign and date the form to certify that the information provided is true.
07
Submit the completed questionnaire as instructed, either electronically or by mail.
Who needs Short Form Health Statement Questionnaire?
01
Individuals applying for health insurance.
02
Patients undergoing medical evaluations for various procedures.
03
Participants in clinical trials or health screening programs.
04
Employees needing health clearances for specific jobs.
05
Anyone requesting medical consultations that require health history.
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What is Short Form Health Statement Questionnaire?
The Short Form Health Statement Questionnaire is a simplified medical questionnaire used to gather essential health information from individuals, often in relation to insurance applications or benefits eligibility.
Who is required to file Short Form Health Statement Questionnaire?
Individuals applying for certain insurance policies or benefits may be required to file the Short Form Health Statement Questionnaire as part of the underwriting process.
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 answer all questions truthfully 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 applicant's health status 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, current medical conditions, medications, and any relevant health-related events such as surgeries or hospitalizations.
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