Health Forms

Completion of the questions below will allow us to provide you with a health insurance plan design best suited for YOU. Before we begin, let's clear up some terminology:

Basic Coverage: economical plans that provide for major medical expenses. Limits are placed on everyday, minor procedures, such as procedures performed in the doctor's office and prescription medication, to lower monthly premiums.

Comprehensive Coverage: feature-rich plans that not only provide for major medical expenses, but also provide extensive coverage for the everyday procedures and needs. The monthly premiums are higher, since the insurance company is more involved in treatment and claims.

Medical Costs: amounts charged to treat an illness or injury. These include doctor visits, labs and x-rays, preventive care (pap smears, mammograms, prostate exams), and prescription medication costs.

Health Savings Account (HSA): a savings account that can be opened anywhere, to coincide with a High Deductible Health Plan. You pay the insurance company a certain amount each month for their services, and you also put money into a Health Savings Account to pay for future major medical expenses. This money earns interest each year, and each year the remaining balance is added to additional deposits.

Now, on with the questionnaire:

*Is this coverage:
Employer Sponsored (Group)
Individual (Not Employer Sponsored)
Not Sure
*Are you, as an individual, interested in a plan that offers Basic coverage, or one that is more Comprehensive?
Basic  Comprehensive  *How willing are you, as an individual, to share in the Medical Costs in exchange for a lower monthly premium?
Not Willing  Somewhat Willing  Very Willing  How many visits to the doctor's office do you make each year?
2 or less  3 to 5  6 or more
They send me a "We Missed You This Week" card if I'm not there every Monday  *What do you feel is a fair amount to pay for health insurance per month?
$150 or less  Between $150 and $200  $200 or more  Not Sure
Are you interested in setting up a Health Savings Account (HSA) to save for future medical expenses?
Yes
No
Not Sure
Thank you. This will provide us the information needed to select a plan that is in line with your needs. Please keep in mind that no plan is perfect; however, we will make every attempt to provide you with a plan of care you are satisfied in utilizing. If you would, tell us a little about yourself: *Your Name: *E-mail Address *Phone Number: *Sex
Male  Female  *Date of Birth Height/Weight (not required if group plan) *Street Address (Including City) Home Zip (not required if group plan) Please provide the name, address and phone number of any physician or specialist you currently see, and would like to continue to visit.
Please provide previous hospitalizations or surgeries for the past 5 yrs, including the dates of the procedures, what was done, and the outcome. Also, the daily dosage of any medications you take, and the reason you were prescribed that medication.

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