Fillable The Standard Medical History Statement (California State University Channel Islands)

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The Standard Medical History Statement (California State University Channel Islands)

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CA
SI 9354-101770 1 of 3 (2/11)
Standard Insurance Company Medical History Statement
920 SW Sixth Avenue Portland OR 97204 For Residents of California
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 work full-time because of any physical or mental condition, or injury? . . . . . . . . . . . . . . . . . . . . . . . . Ye s No
2. Has a 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 ailment, or digestive system disorder? . . . . . . . . . . . . . Ye s No
B. Multiple sclerosis, epilepsy, stroke, paralysis, numbness, visual disturbance, blindness, deafness, or any other neurological or
muscle disorder? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ye s No
C. Cancer, tumor, lesions, leukemia, lymphoma, blood clotting or other malignancy or growth? . . . . . . . . . . . . . . . . . . . . . . Ye s No
D. Cardiovascular disease, heart ailment, arteriosclerosis, abnormal pulse, high blood pressure, heart murmur, valve, circulatory,
or vascular disorders? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ye s No
E. Emphysema, asthma, bronchitis, sleep apnea, or other respiratory or lung disease? . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ye s No
F. Lupus, scleroderma, vasculitis, connective tissue disease, or other immune system disorder not related to Human
Immunodeficiency Disorder (HIV)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ye s No
G. Osteoarthritis, rheumatoid arthritis, osteoporosis, pain in the joints, amputations, or other disease or disorder of the bones, joints,
back, or spine, arthritic or disc conditions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ye s No
H. Diabetes, thyroid, gland, spleen, or nephritis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ye s No
I. Drug or alcohol abuse, or have you used alcohol, drugs or nicotine in a manner that has resulted in medical treatment? . . . Ye s No
J. Psychiatric or mental condition, depression, adjustment disorder, affective disorder, anxiety disorder, or obsessive-
compulsive disorder? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ye s No
3. In the past 10 years have you had any illness or injury not listed above which resulted in the use of prescribed medication or
physician visits? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ye s No
4. Has a medical professional ever diagnosed you as having or prescribed medication to you for Acquired Immune Deficiency
Syndrome (AIDS) or AIDS-Related Complex (ARC)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ye s No
5. Are you currently pregnant? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ye s No
MEDICAL HISTORY STATEMENT QUESTIONS
Height Weight Physician or Medical Facility with Applicant’s Complete Medical Records
Name and Full Mailing Address
APPLICATION INFORMATION
Type of Application
(check one)
Initial
Increase in Coverage
Late Application
Check the insurance coverage you are requesting.
Voluntary Long Term Disability + =
Voluntary Life + =
Spouse Life + =
Name of Group Group Number Check who is Applying
(One per form)
Member/Employee Name Birthdate (Mo/Day/Year) Date Hired (Mo/Day/Year)
Occupation Salary Social Security Number Member/Employee Identification No.
MEMBER/EMPLOYEE INFORMATION
Member/Employee
Spouse
Applicant’s Name (Person to be insured) Street Address City State Zip
Sex Birthdate
(Mo/Day/Year) Birthplace Social Security Number Work Phone ( )
Home Phone ( )
M
F
APPLICANT INFORMATION
Read the Information Practices Notice(s) on page 3. A separate form must be submitted for each applicant (Employee, Member and Spouse
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 2. Keep a copy for your records, and send the original to Standard Insurance Company in the reply envelope provided.
DIRECTIONS FOR APPLYING FOR COVERAGE
The California State University 101770/648379
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
Reset
CA
SI 9354-101770 2 of 3 (2/11)
Applicant Name
(to be completed if applying online)
Social Security Number
Describe below any “yes” answers. (Please provide the entire question number.)
Question Description of Injuries, Disorders Month/Year Duration Final Result Physicians Consulted,
Number and Operations City & State
•
I represent that the statements contained herein, including those made in response to the Medical History Statement questions and any
attachments, 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, medical facility, insurance or reinsurance company, and
the Medical Information Bureau 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 Deficiency
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 obtained by authorization 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 understand The Standard may release information it has about me to the 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 benefits.
•
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 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 beneficiary designation on file with my plan administrator, I understand the
designation(s) on file will also apply to any approved amounts. If I have no beneficiary designation(s) on file or I wish to change the name of
the current beneficiary(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 I have kept a copy of this Medical History Statement.
•
I understand that I am entitled to receive a copy of this authorization. This authorization will remain valid one year 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.
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 Date
CA
SI 9354-101770 3 of 3 (2/11)
•
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. (Medical Information Bureau). We will use the
authorization you signed on this form when we seek this information.
•
MIB (MEDICAL INFORMATION BUREAU) – Information regarding your insurability will be treated as confidential. Standard Insurance Company or
its reinsurers may, however, make a brief report thereon to MIB, a not-for-profit 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 insurance coverage, or a claim for
benefits is submitted to such a company, MIB, upon request, will supply such company with the information in its file.
Upon receipt of a request from you, MIB will arrange disclosure of any information it may have in your file. Please contact MIB at 866-692-6901
(TTY 866-346-3642). If you question the accuracy of information in MIB’s file, 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: Post Office Box 105, Essex Station, Boston,
Massachusetts 02112.
Standard Insurance Company may release information in its file to its reinsurers, and Standard Insurance Company, or its reinsurers, may release
information in its file to other insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may
be submitted.
•
DISCLOSURE TO OTHERS – The information collected about you is confidential. 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 file. 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 justified. 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
(to be completed if applying online)
Social Security Number
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The Standard Medical History Statement (California State University Channel Islands)

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Completed 21 July 2020

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