Anthem Enrollment Application
Social Security no.* (required)
Section E: Medical information 1. Has anyone listed on this application ever had medical advice, treatment or do you know, or have reasons to know, of health problems in regard to the following? Check Yes or No. a. Cancer, tumor, or neoplasm † Yes No b. Organ transplantation Yes No c. Disorders of the heart or circulatory system Yes No d. Hepatitis Yes No 2. Is anyone listed on this application pregnant? Yes No If yes, when is the expected due date? 3. Has any applicant been advised to undergo a surgical operation or procedure within the last six months? Yes No 4. Is any applicant currently taking prescription drugs? Yes No If yes, please list on a separate sheet and attach. 5. Has anyone applying for coverage been treated for a serious illness (For example: cancer, diabetes, heart disease, cardiovascular disease, AIDS or AIDS– related disease, pregnancy, mental/nervous disorder, substance abuse, or any illnesses related to a major body organ) been hospitalized, had surgery, OR incurred healthcare claims in excess of $7,500 in the last 12 months? Yes No This section MUST be completed if you answered “Yes” to any questions 1–5 above. Person treated Name of illness or disorder Type of treatment received Treatment dates From:
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14 STERLING ESTATES 2023 BENEFITS GUIDE
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