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Application Form

BCBS 7350 EPO 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

Health Disclosures — Next 12 Months (All questions MUST be answered NO to Qualify)

Is the prospective client, 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

Health Disclosures — Past 5 Years (All questions MUST be answered NO to Qualify)

Please answer the following questions for yourself, your spouse, and any dependents included in the application for coverage. NOTE: Dependent children are covered until the end of the month in which they turn 26. Domestic partners are not eligible for coverage— only legal spouses qualify.

1. Has the prospective client or any of his/her dependents been under a doctor's care currently or within the past five years for any of the following conditions: cancer, heart disease (including bypass), heart attack, heart surgery, or stroke?
Yes No

2. Has the prospective client or any of his/her dependents applying for coverage been home-bound, incapacitated, or incapable of self-support due to a medical condition within the past five years?
Yes No

3. Has the prospective client or any of his/her dependents applying for coverage been under a doctor's care currently or within the past five years for an autoimmune or blood disease (e.g., lupus, MS, anemia, AIDS, HIV, hemophilia, IBS, or Crohn's)?
Yes No

4. Has the prospective client or any of his/her dependents been under a doctor's care currently or within the past five years for organ failure or an organ transplant involving the kidney, liver, lung, or heart, or for any form of organ support (e.g., dialysis)?
Yes No

5. Is the prospective client or any of his/her dependents applying for coverage currently pregnant or expecting?
Yes No

6. Is the prospective client or any of his/her dependents currently receiving treatment for a condition that required hospitalization within the past five years?
Yes No

7. Has the prospective client or any of his/her dependents been under a doctor's care currently or within the past five years for a respiratory disorder, such as emphysema, chronic bronchitis, COPD, or chronic pneumonia? (asthma with no asthma related hospitalizations should be answered NO)
Yes No

8. Has the prospective client or any of his/her dependents seeking coverage been under a doctor's care currently or within the past five years for a musculoskeletal disorder, such as back disorders, muscular dystrophy, cerebral palsy, dermatomyositis, compartment syndrome, sciatica, or osteoporosis?
Yes No

9. Has the prospective client or any of his/her dependents seeking coverage been under a doctor's care currently or within the past five years for alcohol or substance abuse or dependency?
Yes No

10. Has the prospective client or any of his/her dependents seeking coverage been under a doctor's care currently or within the past five years for Type 1 diabetes, required insulin on a semi-regular or regular basis, or been under the care of a healthcare professional for any diabetes-related conditions? (Type 2 diabetes with non-insulin should be answered NO)
Yes No

11. Has the prospective client or any of his/her dependents seeking coverage been under a doctor's care currently or within the past five years for a previous major surgery, or have an upcoming planned surgery?
Yes No

Signature

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Please type full name

Date (auto-filled)

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