Is anyone currently hospitalized, confined at home, incapacitated, confined in a treatment facility, incapable of self-support because of physical or mental disability?
Has anyone been treated for a serious illness, been hospitalized or had surgery in the past 5 years?
Has anyone been advised that medical treatment, diagnostic testing, surgery or hospitalization is necessary?
Is anyone currently being treated or been advised to seek treatment for any of the following?
Please include names, and details on illnesses as they related to the above questions.
"In the event that material information has been omitted or is inaccurate, the insurance carrier may deny, limit or retroactively terminate coverage back to the coverage inception date. Furthermore, the Guided Benefits service agreement may also terminate for breach of contract resulting from the material misrepresentation. In such cases, I understand that Guided Benefits also may adjust my
insurance premiums to properly reflect the underwriting risk present at the time of the original misrepresentation."
Guided Benefits gathers this information for statistical and actuarial use only. This information is not to be used in connection with any decisions or actions regarding any individual's employment. Prospective employees in Michigan should not provide information regarding height or weight.
Guided Benefits Program Notice of Privacy Practices provides more detailed information about how the Guided Benefits Program and the health plan I have chosen may use and disclose my protected health information. I have a legal right to review this Notice of Privacy practices before I sign this consent and I am encouraged to read it in full. I have a right to request restrictions on how my protected health information is used and disclosed. The Guided Benefits Program and my health plan are not required by law to grant my request. However, if my request is granted, Guided Benefits Program and my health plan are bound by their agreement. I have a right to revoke this consent in writing, except to the extent the Guided Benefits Program or my health plan have already used or disclosed my protected health information in reliance upon my consent.
Information disclosed on this form is considered valid for effective dates within 90 days of date signed. I will notify Guided Benefits of any changes that occur after signing this Group Major Illness Questionnaire and prior to starting health coverage with Guided Benefits. I understand that Guided Benefits reserves the right to re-underwrite based on a change in the Census or Demographics.