PHQ:
Personal Health Questionnaire
Do you plan on enrolling in the Association Affinity Health Plan?
I plan on enrolling in the Health Plan
I plan on waiving coverage from the Health Plan
Member Name
Phone
Email
Address
Company Name
Hire Date
MM
/
DD
/
YYYY
Are you coming off of furlough?
Yes, I am coming off of furlough
No, I am not coming off of furlough
Pharmacy Assistance Program Income Qualification
Please input the range of your pre-tax household yearly income.
This information is used solely to verify Federal Poverty Level (FPL) and apply potential pharmaceutical savings and will not be shared with any third-party.
25K-50K
50K-75K
75K-100K
100K-150K
150K-200K
200K+
How many people are in your household?
Enter # of household residents.
Date Furloughed
MM
/
DD
/
YYYY
Date returned from Furlough
MM
/
DD
/
YYYY
I. Demographic Build & Tobacco Use
• Answer all of the following questions for yourself and enrolling family members.
• All questions must be answered, or the form may not be accepted.
Social Security Number
Gender
Male
Female
Male
Date of Birth
MM
/
DD
/
YYYY
Height
(ft)
1
2
3
4
5
6
7
8
5
Height
(in)
1
2
3
4
5
6
7
8
9
10
11
5
Weight
(lb)
Tobacco Use In Last Year?
Yes
No
Are you adding a Spouse/Domestic Partner?
Yes
No
Spouse Name
Date of Birth
MM
/
DD
/
YYYY
Social Security Number - Spouse
Gender
Male
Female
Male
Height
(ft)
1
2
3
4
5
6
7
8
5
Height
(in)
1
2
3
4
5
6
7
8
9
10
11
5
Weight
(lb)
Zip Code
Tobacco Use In the Last Year?
Yes
No
Are you adding Child/Children?
Yes
No
Child #1
Social Security Number (1)
Gender (1)
Male
Female
Male
Date of Birth (1)
MM
/
DD
/
YYYY
Height (1)
(ft)
1
2
3
4
5
6
7
8
5
Height (1)
(in)
1
2
3
4
5
6
7
8
9
10
11
5
Weight (1)
(lb)
Zip Code (1)
Tobacco Use In the Last Year? (1)
Yes
No
Add 2nd child?
Yes
No
Child #2
Child #2
Social Security Number (2)
Gender (2)
Male
Female
Male
Date of Birth (2)
MM
/
DD
/
YYYY
Height (2)
(ft)
1
2
3
4
5
6
7
8
5
Height (2)
(in)
1
2
3
4
5
6
7
8
9
10
11
5
Weight (2)
(lb)
Zip Code (2)
Tobacco Use In the Last Year? (2)
Yes
No
Add 3rd child?
Yes
No
Child #3
Social Security Number (3)
Gender (3)
Male
Female
Male
Date of Birth (3)
MM
/
DD
/
YYYY
Height (3)
(ft)
1
2
3
4
5
6
7
8
5
Height (3)
(in)
1
2
3
4
5
6
7
8
9
10
11
5
Weight (3)
(lb)
Zip Code (3)
Tobacco Use In the Last Year? (3)
Yes
No
Add 4th child?
Yes
No
Child #4
Social Security Number (4)
Gender (4)
Male
Female
Male
Date of Birth (4)
MM
/
DD
/
YYYY
Height (4)
(ft)
1
2
3
4
5
6
7
8
5
Height (4)
(in)
1
2
3
4
5
6
7
8
9
10
11
5
Weight (4)
(lb)
Zip Code (4)
Tobacco Use In the Last Year? (4)
Yes
No
Add 5th child?
Yes
No
Child #5
Social Security Number (5)
Gender (5)
Male
Female
Male
Date of Birth (5)
MM
/
DD
/
YYYY
Height (5)
(ft)
1
2
3
4
5
6
7
8
5
Height (5)
(in)
1
2
3
4
5
6
7
8
9
10
11
5
Weight (5)
(lb)
Zip Code (5)
Tobacco Use In the Last Year? (5)
Yes
No
II. Medical Conditions & Treatments
Has any person listed above seen a medical provider, had treatment recommended, received care (including prescriptions) or been hospitalized for any of the following within the last 5 years?
Check 'YES' or 'NO' for each question.
Please complete ADDITIONAL DETAIL SECTION for ALL 'Yes' answers
1. Cancer
Yes
No
Location and Type of Cancer
Check One
Stage 1
Stage 2
Stage 3
Stage 4 or Higher
2. Cardiac or Heart Disease/Disorder
Yes
No
Check all that apply
Heart Attack
Bypass surgery or angioplasty on single vessel
Bypass surgery on multiple vessels
Other
Please specify
3. Diabetes
Yes
No
List the three most recent HbA1c/fasting blood sugar levels
1) Blood Sugar Level
2) Blood Sugar Level
3) Blood Sugar Level
4. High Cholesterol
Yes
No
List the three most recent Cholesterol readings:
1) High Cholesterol
2) High Cholesterol
3) High Cholesterol
5. High Blood Pressure
Yes
No
List the three most recent readings:
1) HBP
2) HBP
3) HBP
6. Arthritis (i.e. rheumatoid, osteo, psoriatic, gout)
Yes
No
7. Autoimmune Disease (i.e. lupus, MS, anemia)
Yes
No
8. Back Disorder
(i.e. degenerative disk disease, herniated disk, spinal fusion, spondylitis, strain)
Yes
No
9. Benign Growth (i.e. tumor, cyst)
Yes
No
10. Bowel (i.e. irritable bowel IBS, Crohn's ileitis)
Yes
No
11. Circulatory System Disease (i.e. stroke, arterial / vascular diseases)
Yes
No
12. Immunodeficiency (i.e. AIDS, HIV+, hemophilia)
Yes
No
13. Kidney Disorder (i.e. nephritis, renal failure)
Yes
No
14. Liver Disease (i.e. cirrhosis, hepatitis A, B, C, E)
Yes
No
15. Mental Illness
(i.e. mild or major depression, anxiety, bipolar disorder, or schizophrenia)
Yes
No
16. Counseling (Current or prior counseling?)
Yes
No
17. Muscular Disorder
Yes
No
18. Respiratory (i.e. asthma, allergies, pneumonia, COPD, emphysema, bronchitis)
Yes
No
19. Stomach (i.e. ulcer, acid reflux, GERD)
Yes
No
20. Substance dependency (i.e. alcohol, drug)
Yes
No
21. Transplants
Yes
No
List or Organ(s):
22. Is anyone currently taking prescription medication(s)?
Yes
No
23. Has anyone had any of the following for a serious illness in the past 5 years?
a) Treatment
b) Hospitalization
c) Surgery
d) No
24. Is anyone currently:
24a) Hospitalized or confined in a treatment facility?
Yes
No
24b) confined at home, incapacitated or incapable of self-support?
Yes
No
25. Is any of the following pending?
25a) Treatment (medical treatment or diagnostic testing)
Yes
No
25b) Hospitalization
Yes
No
25c) Surgery
Yes
No
26. In the past 5 years, has anyone enrolling had symptoms of any serious medical condition not yet indicated on this form?
Yes
No
III. Pregnancy and Childbirth
Is anyone pregnant?
Yes
No
a) The due date is:
MM
/
DD
/
YYYY
b) Is this a High Risk Pregnancy, any complications or bleeding?
Yes
No
c) Previous c-section or pre-term birth?
Yes
No
d) Are multiple births expected?
Yes
No
Expected multiple birth:
Twins
Triplets
Other
How many children are expected?
Additional Details
Please answer the following questions below for ALL above questions answered 'YES'
#1: Cancer
Name of Individual (#1)
Condition/Diagnosis (#1)
Date of Onset (#1)
MM
/
DD
/
YYYY
Last treated Date (#1)
MM
/
DD
/
YYYY
Treatment/Drug (#1)
Still Taking? (#1)
Yes
No
Degree of Recovery (#1)
#2 Cardiac or Heart Disease
Name of Individual (#2)
Condition/Diagnosis (#2)
Date of Onset (#2)
MM
/
DD
/
YYYY
Last treated Date (#2)
MM
/
DD
/
YYYY
Treatment/Drug (#2)
Still Taking? (#2)
Yes
No
Degree of Recovery (#2)
#3 Diabetes
Name of Individual (#3)
Condition/Diagnosis (#3)
Date of Onset (#3)
MM
/
DD
/
YYYY
Last treated Date (#3)
MM
/
DD
/
YYYY
Treatment/Drug (#3)
Still Taking? (#3)
Yes
No
Degree of Recovery (#3)
#4 High Cholesterol
Name of Individual (#4)
Condition/Diagnosis (#4)
Date of Onset (#4)
MM
/
DD
/
YYYY
Last treated Date (#4)
MM
/
DD
/
YYYY
Treatment/Drug (#4)
Still Taking? (#4)
Yes
No
Degree of Recovery (#4)
#5 High blood pressure
Name of Individual (#5)
Condition/Diagnosis (#5)
Date of Onset (#5)
MM
/
DD
/
YYYY
Last treated Date (#5)
MM
/
DD
/
YYYY
Treatment/Drug (#5)
Still Taking? (#5)
Yes
No
Degree of Recovery (#5)
#6 Arthritis
Name of Individual (#6)
Condition/Diagnosis (#6)
Date of Onset (#6)
MM
/
DD
/
YYYY
Last treated Date (#6)
MM
/
DD
/
YYYY
Treatment/Drug (#6)
Still Taking? (#6)
Yes
No
Degree of Recovery (#6)
#7 Autoimmune Disease
Name of Individual (#7)
Condition/Diagnosis (#7)
Date of Onset (#7)
MM
/
DD
/
YYYY
Last treated Date (#7)
MM
/
DD
/
YYYY
Treatment/Drug (#7)
Still Taking? (#7)
Yes
No
Degree of Recovery (#7)
#8: Back Disorder
Name of Individual (#8)
Condition/Diagnosis (#8)
Date of Onset (#8)
MM
/
DD
/
YYYY
Last treated Date (#8)
MM
/
DD
/
YYYY
Treatment/Drug (#8)
Still Taking? (#8)
Yes
No
Degree of Recovery (#8)
#9: Benign Growth
Name of Individual (#9)
Condition/Diagnosis (#9)
Date of Onset (#9)
MM
/
DD
/
YYYY
Last treated Date (#9)
MM
/
DD
/
YYYY
Treatment/Drug (#9)
Still Taking? (#9)
Yes
No
Degree of Recovery (#9)
#10: Bowel
Name of Individual (#10)
Condition/Diagnosis (#10)
Date of Onset (#10)
MM
/
DD
/
YYYY
Last treated Date (#10)
MM
/
DD
/
YYYY
Treatment/Drug (#10)
Still Taking? (#10)
Yes
No
Degree of Recovery (#10)
#11: Circulatory System Disease
Name of Individual (#11)
Condition/Diagnosis (#11)
Date of Onset (#11)
MM
/
DD
/
YYYY
Last treated Date (#11)
MM
/
DD
/
YYYY
Treatment/Drug (#11)
Still Taking? (#11)
Yes
No
Degree of Recovery (#11)
#12: Immunodeficiency
Name of Individual (#12)
Condition/Diagnosis (#12)
Date of Onset (#12)
MM
/
DD
/
YYYY
Last treated Date (#12)
MM
/
DD
/
YYYY
Treatment/Drug (#12)
Still Taking? (#12)
Yes
No
Degree of Recovery (#12)
#13 Kidney Disorder
Name of Individual (#13)
Condition/Diagnosis (#13)
Date of Onset (#13)
MM
/
DD
/
YYYY
Last treated Date (#13)
MM
/
DD
/
YYYY
Treatment/Drug (#13)
Still Taking? (#13)
Yes
No
Degree of Recovery (#13)
#14: Liver Disease
Name of Individual (#14)
Condition/Diagnosis (#14)
Date of Onset (#14)
MM
/
DD
/
YYYY
Last treated Date (#14)
MM
/
DD
/
YYYY
Treatment/Drug (#14)
Still Taking? (#14)
Yes
No
Degree of Recovery (#14)
#15: Mental Illness
Name of Individual (#15)
Condition/Diagnosis (#15)
Date of Onset (#15)
MM
/
DD
/
YYYY
Last treated Date (#15)
MM
/
DD
/
YYYY
Treatment/Drug (#15)
Still Taking? (#15)
Yes
No
Degree of Recovery (#15)
#16: Counseling
Name of Individual (#16)
Condition/Diagnosis (#16)
Date of Onset (#16)
MM
/
DD
/
YYYY
Last treated Date (#16)
MM
/
DD
/
YYYY
Treatment/Drug (#16)
Still Taking? (#16)
Yes
No
Degree of Recovery (#16)
#17: Muscular Disorder
Name of Individual (#17)
Condition/Diagnosis (#17)
Date of Onset (#17)
MM
/
DD
/
YYYY
Last treated Date (#17)
MM
/
DD
/
YYYY
Treatment/Drug (#17)
Still Taking? (#17)
Yes
No
Degree of Recovery (#17)
#18: Respiratory
Name of Individual (#18)
Condition/Diagnosis (#18)
Date of Onset (#18)
MM
/
DD
/
YYYY
Last treated Date (#18)
MM
/
DD
/
YYYY
Treatment/Drug (#18)
Still Taking? (#18)
Yes
No
Degree of Recovery (#18)
#19: Stomach
Name of Individual (#19)
Condition/Diagnosis (#19)
Date of Onset (#19)
MM
/
DD
/
YYYY
Last treated Date (#19)
MM
/
DD
/
YYYY
Treatment/Drug (#19)
Still Taking? (#19)
Yes
No
Degree of Recovery (#19)
#20: Substance dependency
Name of Individual (#20)
Condition/Diagnosis (#20)
Date of Onset (#20)
MM
/
DD
/
YYYY
Last treated Date (#20)
MM
/
DD
/
YYYY
Treatment/Drug (#20)
Still Taking? (#20)
Yes
No
Degree of Recovery (#20)
#21: Transplants
Name of Individual (#21)
Condition/Diagnosis (#21)
Date of Onset (#21)
MM
/
DD
/
YYYY
Last treated Date (#21)
MM
/
DD
/
YYYY
Treatment/Drug (#21)
Still Taking? (#21)
Yes
No
Degree of Recovery (#21)
#22: Prescription Medication (1)
Name of Individual (#22)
Condition/Diagnosis (#22)
Date of Onset (#22)
MM
/
DD
/
YYYY
Last treated Date (#22)
MM
/
DD
/
YYYY
Treatment/Drug (#22)
Still Taking? (#22)
Yes
No
Degree of Recovery (#22)
#23a: TREATMENT for a serious illness in last 5 years
Name of Individual (#23a)
Condition/Diagnosis (#23a)
Date of Onset (#23a)
MM
/
DD
/
YYYY
Last treated Date (#23a)
MM
/
DD
/
YYYY
Treatment/Drug (#23a)
Still Taking? (#23a)
Yes
No
Degree of Recovery (#23a)
#23b: HOSPITALIZATION for a serious illness in last 5 years
Name of Individual (#23b)
Condition/Diagnosis (#23b)
Date of Onset (#23b)
MM
/
DD
/
YYYY
Last treated Date (#23b)
MM
/
DD
/
YYYY
Treatment/Drug (#23b)
Still Taking? (#23b)
Yes
No
Degree of Recovery (#23b)
#23c: SURGERY for a serious illness in last 5 years
Name of Individual (#23c)
Condition/Diagnosis (#23c)
Date of Onset (#23c)
MM
/
DD
/
YYYY
Last treated Date (#23c)
MM
/
DD
/
YYYY
Treatment/Drug (#23c)
Still Taking? (#23c)
Yes
No
Degree of Recovery (#23c)
#24a: CURRENTLY hospitalized or confined in a treatment facility
Name of Individual (#24a)
Condition/Diagnosis (#24a)
Date of Onset (#24a)
MM
/
DD
/
YYYY
Last treated Date (#24a)
MM
/
DD
/
YYYY
Treatment/Drug (#24a)
Still Taking? (#24a)
Yes
No
Degree of Recovery (#24a)
#24b: CURRENTLY confined at home, incapacitated, or incapable of self support
Name of Individual (#24b)
Condition/Diagnosis (#24b)
Date of Onset (#24b)
MM
/
DD
/
YYYY
Last treated Date (#24b)
MM
/
DD
/
YYYY
Treatment/Drug (#24b)
Still Taking? (#24b)
Yes
No
Degree of Recovery (#24b)
#25a: PENDING TREATMENT (medical or diagnostic)
Name of Individual (#25a)
Condition/Diagnosis (#25a)
Date of Onset (#25a)
MM
/
DD
/
YYYY
Last treated Date (#25a)
MM
/
DD
/
YYYY
Treatment/Drug (#25a)
Still Taking? (#25a)
Yes
No
Degree of Recovery (#25a)
#25b: PENDING HOSPITALIZATION
Name of Individual (#25b)
Condition/Diagnosis (#25b)
Date of Onset (#25b)
MM
/
DD
/
YYYY
Last treated Date (#25b)
MM
/
DD
/
YYYY
Treatment/Drug (#25b)
Still Taking? (#25b)
Yes
No
Degree of Recovery (#25b)
#25c: PENDING SURGERY
Name of Individual (#25c)
Condition/Diagnosis (#25c)
Date of Onset (#25c)
MM
/
DD
/
YYYY
Last treated Date (#25c)
MM
/
DD
/
YYYY
Treatment/Drug (#25c)
Still Taking? (#25c)
Yes
No
Degree of Recovery (#25c)
#26: SYMPTOMS of a serious illness in last 5 years
Name of Individual (#26)
Condition/Diagnosis (#26)
Date of Onset (#26)
MM
/
DD
/
YYYY
Last treated Date (#26)
MM
/
DD
/
YYYY
Treatment/Drug (#26)
Still Taking? (#26)
Yes
No
Degree of Recovery (#26)
#27: PREGNANCY: Is anyone pregnant
Name of Individual (#27)
Condition/Diagnosis (#27)
Date of Onset (#27)
MM
/
DD
/
YYYY
Last treated Date (#27)
MM
/
DD
/
YYYY
Treatment/Drug (#27)
Still Taking? (#27)
Yes
No
Degree of Recovery (#27)
#27b: PREGNANCY: High Risk, complications, bleeding
Name of Individual (#27b)
Condition/Diagnosis (#27b)
Date of Onset (#27b)
MM
/
DD
/
YYYY
Last treated Date (#27b)
MM
/
DD
/
YYYY
Treatment/Drug (#27b)
Still Taking? (#27b)
Yes
No
Degree of Recovery (#27b)
#27c: PREGNANCY: Previous c-section or pre-term birth
Name of Individual (#27c)
Condition/Diagnosis (#27c)
Date of Onset (#27c)
MM
/
DD
/
YYYY
Last treated Date (#27c)
MM
/
DD
/
YYYY
Treatment/Drug (#27c)
Still Taking? (#27c)
Yes
No
Degree of Recovery (#27c)
In the event that information submitted on this form constitutes fraud or there is an intentional misrepresentation of the material fact, the plan may rescind coverage, for either the individual or the entire group. In any such case, I understand that the plan will return any contributions that have previously been paid as to the rescinded coverage. I certify that the statements are true and correct to the best of my knowledge. I understand that this form is used for information only and does not bind coverage.
Conquer 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 inMichigan should not provide information regarding height or weight. In compliance with requirements for GINA, Conquer is not requesting genetic information.
Conquer Program Notice of Privacy Practices provides more detailed information about how Conquer 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 Conquer Program and my health plan are not required by law to grant my request. However, if my request is granted, the Conquer 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 Conquer Program or my health plan have already used or disclosed my protected health information in reliance upon my consent. I will notify Conquer of any healthor enrollment related changes that occur after signing this form up to the effective date of coverage on the health plan.
By signing this PHQ, I acknowledge that I am self-employed and upon approval and payment of premium, I will automatically become a passive, non-voting certificate class member of Employers Business Alliance, LLC. This certificate of membership will remain in force for a long as I continue to participate in or benefits offered through EBA, LLC. I further understand that while I have certificate membership in EBA, LLC., that affords me no managerial status, voting rights or rights to profits or liabilities. I grant full managerial duties to the duly appointed managers of EBA, LLC., a manager-managed LLC. Additionally, by becoming a Certificate Member, I acknowledge that I will only have access to consulting services and products specifically designed for EBA, LLC. members. Member understands and agrees the Plan may modify health care fees or be terminated based on Member's experience and/or utilization. Any such modification or termination must be presented to the member 60 days prior to the members renewal date.
Client Privacy Notification
Thank you for completing the requested information. Any information, including non-public personal health information, such as name, address and social security number, including detailed protected health information provided will be used for the sole purpose of providing a risk assessment to the health plan that will provide a health care benefit quote to your employer. The AAHP's actuary is a legally contracted underwriter acting as a Business Associate to the AAHP Program and is subject to certain provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations. The AAHP's actuary and underwriter will not sell, license, transmit or disclose this information outside of their offices except as: a) necessary for them to provide the services on behalf of the health plan, b) expressly authorized by you, c) necessary for backup documentation purposes, or d) required by law.
Signature
Clear
Signature Date
MM
/
DD
/
YYYY
Verification
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