Fillable Medical History Statement Standard Insurance Company Florida DIRECTIONS

Fill Online, Printable, Fillable, Blank Medical History Statement Standard Insurance Company Florida DIRECTIONS Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Medical History Statement Standard Insurance Company Florida DIRECTIONS

On average this form takes 29 minutes to complete

The Medical History Statement Standard Insurance Company Florida DIRECTIONS form is 4 pages long and contains:

  • 0 signatures
  • 4 check-boxes
  • 114 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
FL
SI 19602 1 of 4 (3/18)
Name of Group Group Number Check who is Applying (One per form)
Member/Employee Name Birth Date (Mo/Day/Year) Date Hired (Mo/Day/Year)
Occupation Salary
Social Security Number
Member/Employee Identication No.
Standard Insurance Company
Medical Underwriting, 900 SW Fifth Avenue Portland OR 97204
Medical History Statement
Florida
Read the Information Practices Notice(s) on page 4. A separate form must be submitted for each applicant (Employee/Member, Spouse and/or
Child) when Evidence Of Insurability or Proof of Good Health is required to apply for coverage. Complete all items, date and sign in the space at
the bottom of page 3. Keep a copy for your records, and send the original to Standard Insurance Company at the address given above.
DIRECTIONS FOR APPLYING FOR COVERAGE
APPLICATION INFORMATION
Check the type and provide details on the amount of coverage you are requesting.
Short Term Disability
Long Term Disability + =
Life + =
Dependents Life + =
Current Amount In Force, if any Additional Amount Requested
Total Amount Requested
Current Amount In Force, if any Additional Amount Requested
Total Amount Requested
Current Amount In Force, if any Additional Amount Requested
Total Amount Requested
Member/Employee
Spouse
Child
MEMBER/EMPLOYEE INFORMATION
Applicant’s Name (Person to be insured) Email Address
Street Address City State/Province ZIP/Postal Code
Sex Birth Date (Mo/Day/Year) Birthplace
Social Security Number
Work Phone ( )
Home Phone ( )
M F
APPLICANT INFORMATION
PHYSICIAN INFORMATION
(Physician name or medical facility with Applicant’s complete medical records—provide name and full mailing address)
Doctor First Name Doctor Last Name
Clinic Name Doctor Phone
Doctor Address City State/Province ZIP/Postal Code
Date Last Consulted
Reason Last Consulted
Reset
FL
SI 19602 2 of 4 (3/18)
Applicant Name Social Security Number
MEDICAL HISTORY STATEMENT QUESTIONS
Check yes or no for each of these questions, and give details for any “yes” answers. Attach a separate sheet if necessary.
1. Are you now unable to maintain full time employment as a result of a diagnosis or treatment by a licensed member of the
medical profession?
........................................................................................
Yes
No
2. Has a licensed medical professional ever treated you for, diagnosed you as having, or prescribed medication for you for any of
the following:
A. Disease of the liver, pancreas, kidney, ulcers, stomach, intestinal disorder, or digestive system disorder?
...............
Yes
No
B. Multiple sclerosis, epilepsy, stroke, paralysis, numbness, visual disturbance, deafness, or another neurological
or muscle disorder?
......................................................................................
Yes
No
C. Cancer (malignancy or growth), leukemia, lymphoma, chronic anemia, or blood clotting
(thrombophlebitis, pulmonary embolism)?
...................................................................
Yes
No
D. Cardiovascular disease, heart ailment, arteriosclerosis, chest pain, high blood pressure, heart murmur, valve,
circulatory or vascular disorder?
...........................................................................
Yes
No
E. Emphysema, asthma, chronic bronchitis, sleep apnea, or other lung disease?
.....................................
Yes
No
F. Lupus, scleroderma, vasculitis, connective tissue disease, or other immune system disorder not related to
Human Immunodeciency Virus (HIV)?
.....................................................................
Yes
No
G. Osteoarthritis, rheumatoid arthritis, osteoporosis, pain in the joints, amputations, or other disease or disorder
of the bones, joints, back or spine, or arthritic conditions?
......................................................
Yes
No
H. Endocrine (including thyroid or adrenal), diabetes?
............................................................
Yes
No
I. Drug, alcohol or nicotine use or abuse, or have you used drugs, alcohol or nicotine in a manner that resulted in
you having to obtain advice, counseling or treatment?
.........................................................
Yes
No
J. Psychiatric or mental condition, depression, adjustment disorder, affective disorder, or obsessive-compulsive disorder?
...
Yes
No
3. Have you tested positive for exposure to the HIV infection or been diagnosed as having AIDS Related Complex
(ARC) or AIDS caused by the HIV infection or other sickness or condition derived from such infection?
..........
Yes
No
4. During the past ve years, have you been in a hospital or other institution for observation, rest, diagnosis, or
treatment of any disease (not related to Human Immunodeciency Virus (HIV)), disorder, condition or injury?
.....
Yes
No
5. In the next two years, do you plan any operation or visit to a licensed medical professional for an existing physical
or mental condition, illness, injury, surgery or pregnancy?
....................................................
Yes
No
6. In the past 7 years, have you received a diagnosis or treatment by a licensed member of the medical
profession, which resulted in the use of prescribed medication, other than for a cold or allergies
?
............. Yes No
Height ______________________________ Weight
___________________________________________
DETAILS OF ANY “YES” ANSWERS ABOVE Note: Do not indicate any information regarding treatment for HIV/AIDS/ARC.
Include diagnosis, start and end dates, duration, type and frequency of treatment, hospitalization,
physician visits, cause, location of disorder, residuals, acute or chronic status, work loss, and operations.
Question # Diagnosis/Description Month/Year Details/Current Status Physicians Consulted, City and State
FL
SI 19602 3 of 4 (3/18)
• I represent that the statements contained herein, including those made in response to the Medical History Statement questions and any supplemental
information, are true and complete to the best of my knowledge and belief, and I understand that they form the basis of any coverage under the
Group Policy(ies). I understand that any misstatements or failure to report information which is material to the issuance of coverage may be used
as a basis for rescission of my insurance and/or denial of payment of a claim. I agree to notify Standard Insurance Company (The Standard) of any
change in my medical condition while my enrollment application is pending. I agree that if my application is approved by The Standard, the effective
date of any coverage will be determined in accordance with the terms of the Group Policy(ies), including any applicable Active Work requirement.
I agree that if my application is declined, The Standard’s liability is limited to the return of any premium which may have been paid.
•
To any health plan, physician, health care provider, hospital, clinic, laboratory, pharmacy, pharmacy benet manager, medical facility, insurance or
reinsurance company, and the MIB, Inc. (MIB), I instruct you to disclose my entire medical record and any other protected health information concerning
me to The Standard or its reinsurers. This includes information on any disorder of the immune system, including Acquired Immune Deciency Syndrome
(AIDS) or other related syndromes or complexes, and any communicable or sexually transmitted disease or disorder. This also includes information
on the diagnosis and treatment of mental illness and the use of alcohol, drugs, and tobacco, but excludes psychotherapy notes.
• By my signature below, I acknowledge that any agreements I have made to restrict my protected health information do not apply to this authorization
and I instruct any of the above to release and disclose my entire medical records without restriction.
• I understand that The Standard will use information to determine my eligibility for group insurance coverage. I understand The Standard may
release information it has about me to its reinsurers and to any person performing business or legal services for The Standard in connection with
my application. I authorize The Standard to release information it has about me to MIB for the purpose of reporting to the MIB information exchange
and for MIB to audit The Standard’s reporting. I understand The Standard may release information it has about me to other insurance companies
to which I have applied for insurance coverage or benets.
• I understand that information disclosed to The Standard pursuant to authorization may be subject to redisclosure with my authorization or as
otherwise permitted by law. Life and disability insurance coverages are not subject to the Privacy Rule under the Health Insurance Portability and
Accountability Act (HIPAA), and therefore release of information to The Standard is not protected under the Act.
• I understand that I am entitled to receive a copy of this authorization. This authorization will remain valid six months from the date of the signature
below. A photocopy or facsimile of this authorization shall be as valid as the original.
• I understand that I have the right to refuse to sign this authorization. I further understand that I have a right to revoke this authorization at any time
by sending a written statement to The Standard, except to the extent it has been relied upon to disclose requested records. I understand that the
revocation of the authorization, or the failure to sign the authorization, may impair The Standard’s ability to evaluate or process my application and
may be a basis for denying my application for insurance coverage.
• I understand that if my application is approved, premiums shall be paid in accordance with the provisions of the Group Policy(ies), and my coverage
will be subject to all terms and conditions of the Group Policy(ies) and state limitations.
• For Member/Employee: If I currently have a Life and/or Trust Life beneciary designation on le with my plan administrator, I understand the
designation(s) on le will also apply to any approved amounts. If I have no beneciary designation(s) on le or I wish to change the name of the
current beneciary(ies), I will contact my plan administrator.
• I understand that insurance on a Spouse or other Dependent, if any, is payable to the Member/Employee, if living, or as provided under the terms
of the Group Policy(ies).
• I acknowledge that I have read and received the Information Practices Notice and Fraud Notice (if applicable), and I have made a copy of this
Medical History Statement.
ACKNOWLEDGMENT AND AUTHORIZATION FOR RELEASE OF INFORMATION (Please read carefully.)
Note: Declinations do not affect either Guarantee Issue Amounts not subject to Evidence Of Insurability or other coverages already in force with
Standard Insurance Company.
Signature of Applicant (or Member/Employee for Dependent Child)
Date
FRAUD NOTICE
Any person who knowingly and with intent to injure, defraud, or deceive any insurer, les a statement of claim or an application containing
any false, incomplete, or misleading information is guilty of felony of the third degree.
Applicant Name Social Security Number
FL
SI 19602 4 of 4 (3/18)
•
To help us determine your eligibility for group insurance we may request information about you from other persons and organizations. For example,
we may request information from your doctor or hospital, other insurance companies, or MIB, Inc. (MIB), formerly known as Medical Information
Bureau. We will use the authorization you signed on this form when we seek this information.
•
MIB – Information regarding your insurability will be treated as condential. Standard Insurance Company or its reinsurers may, however, make a
brief report thereon to MIB, a not-for-prot membership organization of insurance companies, which operates an information exchange on behalf
of its Members. If you apply to another MIB Member company for life or health (including short and long term disability) insurance coverage, or a
claim for benets is submitted to such a company, MIB, upon request, will supply such company with the information in its le.
Upon receipt of a request from you, MIB will arrange disclosure of any information it may have in your le. Please contact MIB at 866-692-
6901. If you question the accuracy of information in MIB’s le, you may contact MIB and seek a correction in accordance with the procedures
set forth in the federal Fair Credit Reporting Act. The address of MIB’s information office is: 50 Braintree Hill Park, Suite 400, Braintree,
Massachusetts 02184-8734.
Standard Insurance Company may release information in its le to its reinsurers, and Standard Insurance Company, or its reinsurers, may
release information in its le to other insurance companies to whom you may apply for life or health (including short and long term disability)
insurance, or to whom a claim for benets may be submitted. Information for consumers about MIB may be obtained on its website at www.mib.com.
•
DISCLOSURE TO OTHERS – The information collected about you is condential. We will not release any information about you without your
authorization, except to the extent necessary to conduct our business or as required or permitted by law.
• YOUR RIGHTS – You have a right to know what information we have about you in our underwriting le. You also have a right to ask us to correct
any information you think is incorrect. We will carefully review your request and make changes when justied. If you would like more information
about this right or our information practices please write to us at Medical Underwriting, Standard Insurance Company, 900 SW Fifth Avenue,
Portland, Oregon 97204 or call 1-800-843-7979.
INFORMATION PRACTICES NOTICE
Applicant Name Social Security Number
Print and Sign
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Medical History Statement Standard Insurance Company Florida DIRECTIONS

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 22 April 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document