Health Insurance Questionnaire

June 13, 2011

Please complete the following questionnaire.

Please provide the information in full without the use of abbreviations.

What are the contact details of your health insurance provider?

Name………………………………….

Telephone number…………………………….

Fax number…………………………………….

E-mail address…………………………………

Address………………………………

City……………………………….Zip………………………………….

Do you need to receive medical care from a particular provider or medical practitioner?

……………………………………………………………..

Where are your claims sent to?

Name………………………………………………………….

Address…………………………………………………………

City…………………………………………Zip……………………………………….

What is the contact information of the individual to whom an insurance policy is to be issued?

Name (in full)…………………………….

Social security number…………………………….

Physical address………………………………..

Phone number…………………..

What is your insurance cover?  …………………………………………………………………..

What is the duration of your insurance cover?  …………………………………………………

Provide the following details of your employer, school or institution

Name………………………………………………………. Telephone Number……………………………

Address…………………………………………………….

City………………………….Zip………………………..

Does the beneficiary suffer from any known chronic illness that requires medical attention?

a.Yes

b.No

If you answer yes to the above question, please provide details of the condition…………………………………

Does the health insurance company offer cover for the following (please tick)?

a.Outpatient care

b.Inpatient care

c. Prescribed medication

d.Dental appliances

e.Home based care

Download Health Insurance Questionnaire in Word Format

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