HEALTH STATEMENT

HEALTH STATEMENT
The following information is requested regarding your health and the health of any member of your family for whom you wish to obtain coverage through NetCare. Please list all names below. Attach additional sheets if necessary. Any misrepresentation of pre-existing impairment, conditions or diseases will void your coverage.

*If applicant or any family member received care under another name, please list other name.

	FAMILY MEMBER NAME	SEX	DATE OF BIRTH	WEIGHT	HEIGHT	SS#
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Section A:

All questions must be marked Yes or No. If "Yes", circle the applicable condition(s) and provide details in Section B.
1. Have you or any applying family member ever received any professional medical advice or treatment for, or had any symptoms pertaining to any of the following conditions?
1a. Brain or Nervous System: such as dizziness, fainting, headaches, shortness s of breath, seizure disorder, epilepsy, paralysis, aneurysm, muscular dystrophy, multiple sclerosis, stroke, cerebral palsy, polio or others?

YESNO
1b. Heart or Cardiovascular System: such as heart disease, chest pain, high or abnormal blood pressure, heart valve problems, heart attack, heart murmur, rheumatic fever, palpitations,or others?

YESNO
1c. Circulatory System: such as varicose veins.peripheral vascular disease, phlebitis,blood clots, bleeding problems, blood disorder,anemia or enlarged lymph g lands, or others?

YESNO
1d. Lungs or Respiratory System: such as asthma, reactive airway disease, bronchitis, hay fever, allergies, sinusitis, emphysema,tuberculosis, cystic fibrosis, chronic obstructive pulmonary disease, breathing difficult y or others?

YESNO
1e . Digestive System: such as mouth, tongue , esophagus or stomach problems, ulcer, gall bladder disorder, liver disease, cirrhosis, jaundice, hepatitis, pancreatitis, colon, intestinal o r rectal problems, bleeding, polyp, hemorrhoids, hernia, or others?

YESNO
1f. Urinary Tract: such as kidney, ureter, bladder, urethral problems, infections, stricture, stone s, or others?

YESNO
1g. Male Reproductive System: such as prostate problems, infertility, impotence, male breast problem, gynecomastia, syphilis, gonorrhea or other venereal disease, or others?

YESNO
1h. Female Reproductive System: such as breast problems, breast implants, abnormal bleeding , amenorrhea, endometriosis, fibroid turners, abnormal Pap test, problem of the ovaries and/or uterus, infertility, in-vitro fertilization, genital warts , syphilis or other venereal disease ,or others?

YESNO
1i .Musculo-Skeletal System: such as neck, spine/back sprain, pain, injury, sciatica, herniated or bulging discs, abnormal curvature of the spine, scoliosis , any problems of the joints, bones , muscle or tendons, arthritis, fractures/residual hardware, dislocation, carpal tunnel syndrome, physically handicapped , amputation, or others?

YESNO
1 j. Metabolic System: such as diabetes , gout, goiter, thyroid, parathyroid or adrenal disorder. growth hormone deficiencies o r immune system disorders such as; lupus, raynauds, acquired immune deficiency syndrome (AIDS), or any other blood disorder, including evaluation for AZT therapy, or others?

YESNO
2. Have you or any applying family member ever had a history of or incidence of the following?
2a. Skin Conditions: such as skin cancer, melanoma, psoriasis, warts, birthmarks, burns, severe acne, dermatitis, eczema or others?

YESNO
2b. Diseases or problems of the eyes, ears, hearing, nose or throat: such as glaucoma, cataract, crossed eye, detached retina, nasal polyps, deviated nasal septum, ear infections,problems with tonsils or adenoids, sleep apnea, or others?

YESNO
2c. Cancer, tumor(s), cyst(s), Leukemia , Hodkins Disease, lymphoma, or others?

YESNO
2d. Alcoholism, drug dependency or substance abuse?

YESNO
2e. Tobacco dependency? (Do you or any applying family member smoke cigarettes?)

YESNO
2f. Congenital abnormalities, birth defects, such as; heart defects, Down's Syndrome, cleftlip or palate, club foot, developmental delay, mental retardation or other neurological orphysical abnormalities, or others?

YESNO
3. Have you or any applying family member received any counseling, professional advice or treatment for: symptoms of depression, anxiety , panic attack s, nervousness, mental or emotional disorder, schizophrenia, behavioral problems, attention deficit disorder, or for any other reason?

YESNO
4. Have you or any applying family member ever had surgery of any kind including:Cosmetic/reconstructive procedure/surgery (including breast implants), or organ transplant surgery?

YESNO
5. Have you or any applying family member ever had: Abnormal laboratory results, blood work, x-ray, EKG, treadmill stress test, nerve conditions, MRI scan, CT scan, ultrasound, or endoscopic procedures?

YESNO
6. Do you or any applying family member have a prosthesis, implants, or retained hardware?

YESNO
7. FOR FEMALE APPLICANTS ONLY (Subscriber, spouse, dependent) Please answer all questions below:
7a. Do you or any of your applying family members have a history of ectopic pregnancy, pregnancy with complications (e.g. gestational diabetes, pre-eclampsia/eclampsia)or miscarriage?

YESNO
7b. As far as you know, are you or any applying female family member now pregnant?

YESNO
7c. If pregnant, when is the expected delivery date:
7d. If not pregnant, when is your last menstrual period:
7e. Have you or any applying family member ever had a pregnancy resulting in cesarean section, or is one anticipated?

YESNO
Section B:

If you have answered ' Yes' to any of the questions in Section A, please give full details below, including the Question number. If additional space is necessary to provide complete information, please attach an additional sheet of paper.
Mark here if there is an attachment

Attachment Included

	QUESTION NO.	NAME OF FAMILY MEMBER	DIAGNOSIS	DATE OF TREATMENT	FULL NAME OF PHYSICIAN CLINIC/HOSPITAL
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Section C:

For yourself and each applying family member, please list the details of visits to a physician, clinic or hospital in the last 5 years, for any reason, including a check-up or physical exam

	FAMILY MEMBER NAME	DATE OF VISIT	REASON FOR EXAMINATION/CHECK-UP	FINDINGS & PRESENT STATUS	FULL NAME OF PHYSICIAN CLINIC/HOSPITAL
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Section D:
Are you or any applying family member currently taking any medication or have you taken any medication in the past 12 months? If "Yes", please list below.

YESNO

	FAMILY MEMBER NAME	NAME OF MEDICATION & CONDITION FOR WHICH MEDICATION WAS PRESCRIBED	DATE FROM/TO	FULL NAME OF PHYSICIAN
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Section E:

Please answer each question. If "Yes", please provided details in the space provided.
8. Are you or any applying family member disabled, hospitalized or receiving medical care in the home at this time?

YESNO
Family Member(s)
Please Explain
9. Have you or any applying family member been advised to undergo further testing, treatment, organ transplant or surgery which has not yet been performed by a physician, dentist, or other provider?

YESNO
Family Member(s)
Please Explain
10. Do you or any applying family member presently have any condition or illness not mentioned previously, or complications or residuals (prosthesis, implants, or retained hardware) remaining following any treatment?

YESNO
Family Member(s)
Please Explain
11. Have you or any applying family member ever had any application for health or life insurance declined, postponed or restricted in any way?

YESNO
Family Member(s)
Please Explain
11. Are you or any of your eligible dependents currently covered, or had coverage with another health care plan in the last 90 days?

YESNO
If YES (choose one)

GroupIndividual
Family Member(s)
Insurance company or plan
AUTHORIZATION

I authorize any physician, practitioner, hospital, medical care institution, insurance company or other organization, person or employer that has any records or knowledge of care, treatment or advice of myself, my spouse or my children to release such information to NetCare or it's representative. This authorization remains in effect as long as necessary to evaluate my application and/or process claims for me and my covered dependent(s). A photographic copy of this authorization shall be valid as the original.

AGREEMENT

I understand that NetCare has the right to reject my application and if so, I will be notified in writing, and that NetCare is not obligated to disclose the reason for refusal.

I understand and agree that if NetCare rejects my application, under no circumstance will any benefits be payable for any person listed on this application.

I understand that by signing this Health Statement and returning it to NetCare, I am applying for health benefits for myself and all of my family members who are listed in this Health Statement.

If any condition, disease or change in health status occurs after you complete this Health Statement, but before the effective date, you must immediately update this Application by submitting a written explanation to NetCare Health Plans. If you fail to provide this updated information, or if you provide any incorrect or incomplete answers on this Health Statement or in future correspondence concerning this Health Statement , your coverage and your family's coverage may be terminated at any time.

Coverage will begin the first of the month following submission of the application unless notification is given by NetCare to change the effective date.
SIGNATURE OF APPLICANT OR LEGAL GUARDIAN

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SIGNATURE OF APPLICANT'S SPOUSE (IF APPLYING)

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SIGNATURE OF FAMILY MEMBER AGE 18 & OVER (IF APPLYING)

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SIGNATURE OF FAMILY MEMBER AGE 18 & OVER (IF APPLYING)

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PRINT NAME
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SIGNATURE OF FAMILY MEMBER AGE 18 & OVER (IF APPLYING)

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HEALTH STATEMENT

Section A:

1. Have you or any applying family member ever received any professional medical advice or treatment for, or had any symptoms pertaining to any of the following conditions?

2. Have you or any applying family member ever had a history of or incidence of the following?

7. FOR FEMALE APPLICANTS ONLY (Subscriber, spouse, dependent) Please answer all questions below:

Section B:

Section C:

Section D:

Section E: