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Application Form

BCBS 1000 PPO Qualifying Questions

General Questions

How would the member like to receive the signature documents upon submission? * SMS Email

Do you now, or will you in the future, require immigration sponsorship for work authorization, e.g. H-IB? * Yes No

Are you legally authorized to work in the United States? * Yes No

Education

Elementary and Secondary: Indicate the highest level of education you have accomplished: *

Degree Received? * Yes No

GED Received? * Yes No

College Undergraduate Degree: Indicate the highest level of education you have accomplished: *

Name of School: *

Location of School: *

College Degree? * Yes No

Type of Degree (College): *

College Other: *

Graduate School? * Yes No

Graduate Degree Type: *

Graduate Other: *

Doctorate? * Yes No

Doctorate Degree Type: *

Doctorate Other: *

Are you currently in an education program? * Yes No

Study Program: *

Study School: *

Licenses and Certifications

Other Certifications/Registrations: *

Household Information

Oldest Age:

Total Dependents:

Tobacco User? Yes No

Drugs (Past 12 Months)

Applicant	Rx/Med & Mg	Reason	Doctor

Medical History (19 Questions – MUST be answered "No") Is the applicant, spouse/domestic partner/significant other, dependent children, or any other member of their household currently being treated for, or expect to be treated for any of the following over the next 12 months?

1. Organ failure, leading to bone marrow or organ transplant * Yes No

2. Any genetic condition that requires cell or gene therapy treatments? * Yes No

3. Any cancer that requires chemotherapy, radiation, bone marrow treatments, and/or cell therapy treatments? * Yes No

4. Kidney failure requiring dialysis treatments? * Yes No

5. High-risk pregnancy or pregnancies involving multiple fetuses? * Yes No

6. Hemophilia, or other blood clotting disorders? * Yes No

7. Receiving treatment for cancer (current or past five years): * Yes No

8. Major treatment in the past 5 years (cancer, heart disease, heart attack, heart surgery, or stroke): * Yes No

9. Home bound/incapacitated due to a medical condition: * Yes No

10. Under care for autoimmune or blood diseases (e.g., Lupus, MS, Anemia, AIDS, HIV, Hemophilia, IBS, Crohn's): * Yes No

11. Under care for any form of organ support (e.g., dialysis): * Yes No

12. Under care for organ failure/transplant (kidney, liver, lung, heart, etc.): * Yes No

13. Currently pregnant or expecting: * Yes No

14. Treated for a condition resulting in hospitalization within the past 5 years: * Yes No

15. Under care for respiratory disorders (other than asthma or sleep apnea): * Yes No

16. Under care for musculoskeletal disorders (e.g., back disorders, muscular dystrophy, cerebral palsy, etc.): * Yes No

17. Under care for substance abuse or substance dependency: * Yes No

18. Under care as a Type 1 Diabetic: * Yes No

19. Under care for a previous major surgery or upcoming planned surgery: * Yes No

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813-699-0885

info@firsthealth-insurancesolutions.com