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Medicare Supplements
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Medicare Advantage Plans
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Name DOB Height Weight Tobacco
Male
Female
Male
Female
If you are applying during Open Enrollment or a Guarantee Issue period, skip the questions below .
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1. Within the past ten (10) years, have you been treated for or diagnosed by a medical professional as having a. Cancer (excluding basal or squamous cell), Hodgkin’s disease, leukemia, or melanoma; even if the conditions are in remission? b. Congestive heart failure, coronary artery disease, peripheral vascular disease, circulatory disorder (excluding high blood pressure), heart disease, enlarged heart, transient ischemic attack, stroke, heart or heart valve surgery, angioplasty, pacemaker, or stent placement? c. Uncontrolled or insulin dependent diabetes, amputation or eye disease due to diabetes, chronic cystitis, Addison’s disease, kidney failure, nephritis, renal insufficiency or kidney dialysis or gangrene? d. Emphysema, chronic bronchitis, chronic obstructive pulmonary disease (COPD), chronic obstructive lung disease (COLD), or any chronic pulmonary disease requiring the use of oxygen? e. Paget’s disease, rheumatoid or disabling arthritis, lupus or other bone or connective tissue disorder? f. Mental or nervous disorder requiring psychiatric treatment, organic brain disorder, Alzheimer’s disease, ALS (Lou Gehrig’s disease), muscular dystrophy, myasthenia gravis, Parkinson’s disease, multiple sclerosis, cerebral palsy, epilepsy, neuropathy, paralysis, senile dementia or other senility disorders or alcohol or drug abuse? g. Are you permanently confined to a nursing facility, permanently bedridden or confined to a wheelchair? h. Have you been admitted to a hospital three or more times in the last two years?
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