PHQ: Personal Health Questionnaire 

 

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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.
Enter # of household residents.
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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.
Male
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5
5
(lb)
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Male
5
5
(lb)
Male
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5
5
(lb)
Child #2
Male
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5
5
(lb)
Male
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5
5
(lb)
Male
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5
5
(lb)
Male
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5
5
(lb)

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
List the three most recent HbA1c/fasting blood sugar levels
List the three most recent Cholesterol readings:
List the three most recent readings:

24. Is anyone currently:

25. Is any of the following pending?

III. Pregnancy and Childbirth

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Additional Details

Please answer the following questions below for ALL above questions answered 'YES'

#1: Cancer

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#2 Cardiac or Heart Disease

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#3 Diabetes

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#4 High Cholesterol

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#5 High blood pressure

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#6 Arthritis

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#7 Autoimmune Disease

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#8: Back Disorder

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#9: Benign Growth

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#10: Bowel

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#11: Circulatory System Disease

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#12: Immunodeficiency

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#13 Kidney Disorder

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#14: Liver Disease

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#15: Mental Illness

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#16: Counseling

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#17: Muscular Disorder

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#18: Respiratory

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#19: Stomach

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#20: Substance dependency

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#21: Transplants

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#22: Prescription Medication (1)

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#23a: TREATMENT for a serious illness in last 5 years

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#23b: HOSPITALIZATION for a serious illness in last 5 years

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#23c: SURGERY for a serious illness in last 5 years

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#24a: CURRENTLY hospitalized or confined in a treatment facility

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#24b: CURRENTLY confined at home, incapacitated, or incapable of self support

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#25a: PENDING TREATMENT (medical or diagnostic)

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#25b: PENDING HOSPITALIZATION

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#25c: PENDING SURGERY

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 #26: SYMPTOMS of a serious illness in last 5 years

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#27: PREGNANCY: Is anyone pregnant

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#27b: PREGNANCY: High Risk, complications, bleeding

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#27c: PREGNANCY: Previous c-section or pre-term birth

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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.
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