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Application Form

PHCS 250 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 (21 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 *

YesNo

2.Any genetic condition that requires cell or gene therapy treatments? *

YesNo

3.Any cancer that requires chemotherapy, radiation, bone marrow treatments, and/or cell therapy treatments? *

YesNo

4.Kidney failure requiring dialysis treatments? *

YesNo

5.Pregnancy *

YesNo

6.Hemophilia, or other blood clotting disorders? *

YesNo

7.Inpatient Mental Health and/or Substance or Alcohol Treatment *

YesNo

Has the applicant, spouse/partner, significant other, or dependent children been seen by a medical provider, had recommended treatment, received care (including prescriptions), or been hospitalized for any of the following within the last 5 years? This includes any current treatment/medications/prescriptions.

1.Cancer (any kind, this includes skin cancer) *

YesNo

2.Heart Disease (such as, but not limited to, heart surgery, including bypass surgery/CABG, heart attack, stroke, heart failure – do not include high blood pressure) *

YesNo

3.Home Bound, incapacitated or incapable of carrying out daily activities (such as dressing, bathing, or feeding) *

YesNo

4.Autoimmune or blood disease *

YesNo

5.Organ failure/transplant for Kidney, Liver, Lung, or Heart *

YesNo

6.Organ support, such as dialysis or ECMO *

YesNo

7.Pregnant, expecting or receiving treatment to become pregnant *

YesNo

8.Hospitalized currently or in the past 5 years (this includes skilled nursing, mental health, substance treatment and rehabilitation facilities) *

YesNo

9.Respiratory Disorders (other than asthma or sleep apnea) *

YesNo

10.Musculoskeletal Disorders, such as sciatica, osteoporosis, cervical/neck/back disorder (including any type of injection or procedure), Muscular Dystrophy, Cerebral Palsy, dermatomyositis, compartment syndrome *

YesNo

11.Substance Abuse or Dependency (including but not limited to alcohol, cocaine, meth, heroin, opioids) *

YesNo

12.Type 1 Diabetes *

YesNo

13.Major Surgery in the past 5 years or any planned or recommended surgeries in the next 12 months. *

YesNo

14.Neurological Disorder, such as Parkinson's Disease, epilepsy, stroke, Alzheimer's, MS (Multiple Sclerosis), ALS (Amyotrophic Lateral Sclerosis) *

YesNo

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