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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 introduction and instructions carefully.
02
Provide your personal information in the designated fields, including your name, date of birth, and contact information.
03
Answer all questions regarding your medical history truthfully, indicating any current or past health conditions.
04
Include information on medications you are currently taking.
05
Fill out any sections regarding family medical history if required.
06
Review your answers for accuracy and completeness.
07
Sign and date the form as required.
Who needs Short Form Health Statement Questionnaire?
01
Individuals applying for health insurance coverage.
02
Participants in wellness programs or health screenings.
03
Those seeking coverage for specific medical treatments or services.
04
Patients undergoing a medical assessment or evaluation.
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What is Short Form Health Statement Questionnaire?
The Short Form Health Statement Questionnaire is a concise form used to collect essential health information from individuals, typically in the context of insurance applications or medical assessments.
Who is required to file Short Form Health Statement Questionnaire?
Individuals applying for certain insurance policies, or those undergoing medical evaluations, may be required to file the Short Form Health Statement Questionnaire to provide relevant 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 health-related information in the required fields, and review their answers for completeness 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 and risks, allowing insurance companies or medical professionals to make informed decisions.
What information must be reported on Short Form Health Statement Questionnaire?
The information that must be reported on the Short Form Health Statement Questionnaire typically includes personal health history, current medical conditions, medications, and any recent medical treatments or surgeries.
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