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INSTRUCTIONS THE STATEMENT OF HEALTH FORM AND THE AUTHORIZATION FORM THAT FOLLOW THIS SECTIONINSTRUCTIONS TO THE SCOREKEEPER (The Record keeper may be the Group Customer, a Third Party Administrator
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Read the instructions carefully before beginning to fill out the form.
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Fill out your personal information accurately, including your name, address, date of birth, etc.
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Provide detailed information about your medical history, including any pre-existing conditions or illnesses.
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If applicable, include information about any medications you are currently taking.
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Sign and date the form once you have completed all sections.

Who needs statement of health forms?

01
Individuals applying for life insurance
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Individuals applying for health insurance
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Individuals applying for disability insurance
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Individuals applying for certain types of employment
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Statement of health forms are documents used to provide information about an individual's health status.
Employees or individuals applying for insurance or benefits may be required to file statement of health forms.
Statement of health forms can typically be filled out by providing information about one's medical history, current health conditions, medications, and any other relevant health information.
The purpose of statement of health forms is to assess an individual's health status and determine eligibility for insurance coverage or benefits.
Information such as medical history, current health conditions, medications, and any other relevant health information must be reported on statement of health forms.
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