• PHQ: Personal Health Questionnaire

    PHQ: Personal Health Questionnaire

    Applying for enrollment in an Affinity Health Plan
  • Format: (000) 000-0000.
  • Requested start date for coverage*
     / /
  • Pharmacy Assistance Program Income Qualification Please input the range of your pre-tax household yearly income.*

  • 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.
  • Date of Birth*
     / /
  • Tobacco use in the last Year*
  • Are you adding a Spouse/Domestic Partner?*
  • Date of Birth (Spouse)*
     / /
  • Tobacco use in the last year*
  • Are you adding Child/Children?*
  • Date of Birth (1)*
     / /
  • Tobacco use in the last year? (1)*
  • Add Second Child?*
  • Date of Birth (2)*
     / /
  • Tobacco use in the last year? (2)*
  • Add Third Child?*
  • Date of Birth (3)*
     / /
  • Tobacco use in the last year? (3)*
  • Add Fourth Child?*
  • Date of Birth (4)*
     / /
  • Tobacco use in the last year? (4)*
  • Add Fifth Child?*
  • Date of Birth (5)*
     / /
  • Tobacco use in the last year? (5)*
  • Add Sixth Child?*
  • Date of Birth (6)*
     / /
  • Tobacco use in the last year? (6)*
  • Add Seventh Child?*
  • Date of Birth (7)*
     / /
  • Tobacco use in the last year? (7)*

  • 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*
  • 1.Date of Onset*
     / /
  • Check One*
  • 1. Last treated Date*
     / /
  • 1. Still Taking?*
  • Add additional family member?*
  • 1a.Date of Onset*
     / /
  • Check One*
  • 1a. Last treated Date*
     / /
  • 1a. Still Taking?*
  • 2. Cardiac or Heart Disease/Disorder*
  • 2. Date of Onset*
     / /
  • Check all that apply*
  • 2. Last treated Date*
     / /
  • 2. Still Taking?*
  • Add additional family members?*
  • 2a. Date of Onset*
     / /
  • 2a. Check all that apply*
  • 2a. Last treated Date*
     / /
  • 2a. Still Taking?*
  • 3. Diabetes*
  • 3. Date of Onset*
     / /
  • 3. Last treated Date*
     / /
  • 3. Still Taking?*
  • Add additional family members?*
  • 3a. Date of Onset*
     / /
  • 3a. Last treated Date*
     / /
  • 3a. Still Taking?*
  • 4. High Cholesterol*
  • 4. Date of Onset*
     / /
  • 4. Last treated Date*
     / /
  • 4. Still Taking?*
  • Add additional family members?*
  • 4a. Date of Onset*
     / /
  • 4a. Last treated Date*
     / /
  • 4a. Still Taking?*
  • 5. High Blood Pressure*
  • 5. Date of Onset*
     / /
  • 5. Last treated Date*
     / /
  • 5. Still Taking?*
  • Add additional family members?*
  • 5a. Date of Onset*
     / /
  • 5a. Last treated Date*
     / /
  • 5a. Still Taking?*
  • 6. Arthritis (i.e. rheumatoid, osteo, psoriatic, gout)*
  • 6. Date of Onset*
     / /
  • 6. Last treated Date*
     / /
  • 6. Still Taking?*
  • Add additional family members?*
  • 6a. Date of Onset*
     / /
  • 6a. Last treated Date*
     / /
  • 6a. Still Taking?*
  • 7. Autoimmune Disease (i.e. lupus, MS, anemia)*
  • 7. Date of Onset*
     / /
  • 7. Last treated Date*
     / /
  • 7. Still Taking?*
  • Add additional family members?*
  • 7a. Date of Onset*
     / /
  • 7a. Last treated Date*
     / /
  • 7a. Still Taking?*
  • 8. Back Disorder  (i.e. degenerative disk disease, herniated disk, spinal fusion, spondylitis, strain)*
  • 8. Date of Onset*
     / /
  • 8. Last treated Date*
     / /
  • 8. Still Taking?*
  • Add additional family members?*
  • 8a. Date of Onset*
     / /
  • 8a. Last treated Date*
     / /
  • 8a. Still Taking?*
  • 9. Benign Growth (i.e. tumor, cyst)*
  • 9. Date of Onset*
     / /
  • 9. Last treated Date*
     / /
  • 9. Still Taking?*
  • Add additional family members?*
  • 9a. Date of Onset*
     / /
  • 9a. Last treated Date*
     / /
  • 9a. Still Taking?*
  • 10. Bowel (i.e. irritable bowel IBS, Crohn's ileitis)*
  • 10. Date of Onset*
     / /
  • 10. Last treated Date*
     / /
  • 10. Still Taking?*
  • Add additional family members?*
  • 10a. Date of Onset*
     / /
  • 10a. Last treated Date*
     / /
  • 10a. Still Taking?*
  • 11. Circulatory System Disease (i.e. stroke, arterial / vascular diseases)*
  • 11. Date of Onset*
     / /
  • 11. Last treated Date*
     / /
  • 11. Still Taking?*
  • Add additional family members?*
  • 11a. Date of Onset*
     / /
  • 11a. Last treated Date*
     / /
  • 11a. Still Taking?*
  • 12. Immunodeficiency (i.e. AIDS, HIV+, hemophilia)*
  • 12. Date of Onset*
     / /
  • 12. Last treated Date*
     / /
  • 12. Still Taking?*
  • Add additional family members?*
  • 12a. Date of Onset*
     / /
  • 12a. Last treated Date*
     / /
  • 12a. Still Taking?*
  • 13. Kidney Disorder (i.e. nephritis, renal failure)*
  • 13. Date of Onset*
     / /
  • 13. Last treated Date*
     / /
  • 13. Still Taking?*
  • Add additional family members?*
  • 13a. Date of Onset*
     / /
  • 13a. Last treated Date*
     / /
  • 13a. Still Taking?*
  • 14. Liver Disease (i.e. cirrhosis, hepatitis A, B, C, E)*
  • 14. Date of Onset*
     / /
  • 14. Last treated Date*
     / /
  • 14. Still Taking?*
  • Add additional family members?*
  • 14a. Date of Onset*
     / /
  • 14a. Last treated Date*
     / /
  • 14a. Still Taking?*
  • 15. Mental Illness  (i.e. mild or major depression, anxiety, bipolar disorder, or schizophrenia)*
  • 15. Date of Onset*
     / /
  • 15. Last treated Date*
     / /
  • 15. Still Taking?*
  • Add additional family members?*
  • 15a. Date of Onset*
     / /
  • 15a. Last treated Date*
     / /
  • 15a. Still Taking?*
  • 16. Counseling (Current or prior counseling?)*
  • 16. Date of Onset*
     / /
  • 16. Last treated Date*
     / /
  • 16. Still Taking?*
  • Add additional family members?*
  • 16a. Date of Onset*
     / /
  • 16a. Last treated Date*
     / /
  • 16a. Still Taking?*
  • 17. Muscular Disorder*
  • 17. Date of Onset*
     / /
  • 17. Last treated Date*
     / /
  • 17. Still Taking?*
  • Add additional family members?*
  • 17a. Date of Onset*
     / /
  • 17a. Last treated Date*
     / /
  • 17a. Still Taking?*
  • 18. Respiratory (i.e. asthma, allergies, pneumonia, COPD, emphysema, bronchitis)*
  • 18. Date of Onset*
     / /
  • 18. Last treated Date*
     / /
  • 18. Still Taking?*
  • Add additional family members?*
  • 18a. Date of Onset*
     / /
  • 18a. Last treated Date*
     / /
  • 18a. Still Taking?*
  • 19. Stomach (i.e. ulcer, acid reflux, GERD)*
  • 19. Date of Onset*
     / /
  • 19. Last treated Date*
     / /
  • 19. Still Taking?*
  • Add additional family members?*
  • 19a. Date of Onset*
     / /
  • 19a. Last treated Date*
     / /
  • 19a. Still Taking?*
  • 20. Substance dependency (i.e. alcohol, drug)*
  • 20. Date of Onset*
     / /
  • 20. Last treated Date*
     / /
  • 20. Still Taking?*
  • Add additional family members?*
  • 20a. Date of Onset*
     / /
  • 20a. Last treated Date*
     / /
  • 20a. Still Taking?*
  • 21. Transplants*
  • 21. Date of Onset*
     / /
  • 21. Last treated Date*
     / /
  • 21. Still Taking?*
  • Add additional family members?*
  • 21a. Date of Onset*
     / /
  • 21a. Last treated Date*
     / /
  • 21a. Still Taking?*
  • 22. Is anyone currently taking prescription medication(s)?*
  • 22. Still Taking? (1)*
  • 22. Date of Onset (1)*
     / /
  • Add additional prescription medication(2)?*
  • 22. Still Taking? (2)*
  • 22. Date of Onset (2)*
     / /
  • Add additional prescription medication? (3)*
  • 22. Still Taking? (3)*
  • 22. Date of Onset (3)*
     / /
  • Add additional prescription medication? (4)*
  • 22. Still Taking? (4)*
  • 22. Date of Onset (4)*
     / /
  • Add additional family members?*
  • 22a. Still Taking? (1)*
  • 22a. Date of Onset (1)*
     / /
  • Add additional prescription medication(2)?*
  • 22a. Still Taking? (2)*
  • 22a. Date of Onset (2)*
     / /
  • Add additional prescription medication? (3)*
  • 22a. Still Taking? (3)*
  • 22a. Date of Onset (3)*
     / /
  • Add additional prescription medication? (4)*
  • 22a. Still Taking? (4)*
  • 22a. Date of Onset (4)*
     / /
  • Add additional family members?*
  • 22b. Still Taking? (1)*
  • 22b. Date of Onset (1)*
     / /
  • Add additional prescription medication(2)?*
  • 22b. Still Taking? (2)*
  • 22b. Date of Onset (2)*
     / /
  • Add additional prescription medication? (3)*
  • 22b. Still Taking? (3)*
  • 22b. Date of Onset (3)*
     / /
  • Add additional prescription medication? (4)*
  • 22b. Still Taking? (4)*
  • 22b. Date of Onset (4)*
     / /
  • 23. Has anyone had any of the following for a serious illness in the past 5 years?*
  • 23a. Date of Onset*
     / /
  • 23a. Last treated Date*
     / /
  • 23a. Still Taking?*
  • Add additional family members?*
  • 23a. Date of Onset*
     / /
  • 23a. Last treated Date*
     / /
  • 23a. Still Taking?*
  • 23b. Date of Onset*
     / /
  • 23b. Last treated Date*
     / /
  • 23b. Still Taking?*
  • Add additional family members?*
  • 23b. Date of Onset*
     / /
  • 23b. Last treated Date*
     / /
  • 23b. Still Taking?*
  • 23c. Date of Onset*
     / /
  • 23c. Last treated Date*
     / /
  • 23c. Still Taking?*
  • Add additional family members?*
  • 23c. Date of Onset*
     / /
  • 23c. Last treated Date*
     / /
  • 23c. Still Taking?*
  • 24. Is anyone currently Hospitalized or confined in a treatment facility?*
  • 24. Date of Onset*
     / /
  • 24. Last treated Date*
     / /
  • 24. Still Taking?*
  • Add additional family members?*
  • 24a. Date of Onset*
     / /
  • 24a. Last treated Date*
     / /
  • 24a. Still Taking?*
  • 25. Is anyone currently confined at home, incapacitated or incapable of self-support?*
  • 25. Date of Onset*
     / /
  • 25. Last treated Date*
     / /
  • 25. Still Taking?*
  • Add additional family members?*
  • 25a. Date of Onset*
     / /
  • 25a. Last treated Date*
     / /
  • 25a. Still Taking?*
  • 26. Pending treatment (medical treatment or diagnostic testing)*
  • 26. Date of Onset*
     / /
  • 26. Last treated Date*
     / /
  • 26. Still Taking?*
  • Add additional family members?*
  • 26a. Date of Onset*
     / /
  • 26a. Last treated Date*
     / /
  • 26a. Still Taking?*
  • 27. Pending or upcoming hospitalization*
  • 27. Date of Onset*
     / /
  • 27. Last treated Date*
     / /
  • 27. Still Taking?*
  • Add additional family members?*
  • 27a. Date of Onset*
     / /
  • 27a. Last treated Date*
     / /
  • 27a. Still Taking?*
  • 28. Pending or upcoming surgery*
  • 28. Date of Onset*
     / /
  • 28. Last treated Date*
     / /
  • 28. Still Taking?*
  • Add additional family members?*
  • 28a. Date of Onset*
     / /
  • 28a. Last treated Date*
     / /
  • 28a. Still Taking?*
  • 29. In the past 5 years, has anyone enrolling had symptoms of any serious medical condition not yet indicated on this form?*
  • 29. Date of Onset*
     / /
  • 29. Last treated Date*
     / /
  • 29. Still Taking?*
  • Add additional family members?*
  • 29a. Date of Onset*
     / /
  • 29a. Last treated Date*
     / /
  • 29a. Still Taking?*
  • 30. Is anyone pregnant?*
  • b) Due date*
     / /
  • c) Is this a high-risk pregnancy, any complications or bleeding?*
  • 30c. Date of Onset*
     / /
  • 30c. Last treated Date*
     / /
  • 30c. Still Taking?*
  • d) Previous c-section or pre-term birth?*
  • 30d. Date of Onset*
     / /
  • 30d. Last treated Date*
     / /
  • 30d. Still Taking?*
  • e) Are multiple births expected?*
  • 30e. Expected multiple birth:*

  • PHI Disclosure

    By signing this application, I understand the following: That if any information submitted on this form constitutes fraud or there is an intentional misrepresentation of the material fact, the plan may rescind healthcare coverage. In any such case, I understand that the plan will return any contributions that have previously been paid as to the rescinded coverage, minus administrative expenses and claims paid. I certify that the statements are true and correct to the best of my knowledge. I understand that this form is used for information purposes only and does not bind coverage. I understand the AAHP gathers this information for statistical and actuarial uses only and it will not be used in connection with decisions or actions regarding employment. That if I am a resident in Michigan, I do not have to provide information regarding height or weight, and that this in compliance with requirements for GINA. That I have read the Client Privacy Notification provided to me in this application. That as a prospective member, I have the right to request restrictions on how my protected health information is used, and that the AAHP is not required by law to grant this request, but if the request is granted, the AAHP is bound by this agreement. I also understand that I have the right to revoke this consent in writing, except to the extent the AAHP Program has already used or disclosed the protected health information in reliance upon my consent. I further understand that the AAHP program will notify me the member of any health or enrollment related changes that occur after signing this form, up to the effective date of coverage

     

    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.

  • Date*
     - -

  •  

    PO Box 450978      |      Westlake, OH 44145      |      877-585-8480

  • Should be Empty: