BUPA Health Insurance (Thailand) Ltd. 104/9 Unit M02-03 The Avenue Chaengwattana Moo 1 Chaengwattana Tungsonghong Laksi Bangkok 10210
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1 BUPA Health Insurance (Thailand) Ltd 104/9 Unit M02-03 The Avenue Chaengwattana Moo 1 Chaengwattana Tungsonghong Laksi Bangkok Tel Fax Application Form Suggestion for filling this application form Please provide your medical and health information as much as possible (It will be benefit for your underwriting and claim reimbursement) For person less than 18 years old, parents can declare medical and health information for and sign for approval. If you have any questions or need anymore information, you can contact customer service via "csc@bupa.co.th" or telephone When you finish filling this form please send back to BUPA Health Insurance (Thailand) Ltd Chaengewattana Branch 104/9 Unit M02-03 The Avenue Chaengwattana Moo 1 Chaengwattana Tungsonghong Laksi Bangkok Tel Fax Company Thai Expat Club.. Type of Business Networking Association... Job Title.... Department.... Starting Date... Personal Title (i.e. Mr., Mrs., Miss., Boy) Sex Male Female Firstname... Lastname... Preferred language Thai Eng Correspondence address Postal code. Tel (Work)... (Home).. (Mobile) ID card no. / Passport No... Date of Birth.... Height cm. Weight.. kg. Home country..... Country of residence... Relationship with the employee (For dependent applicant) Spouse Child NAME OF BENEFICIARY (FOR MEMBER WHO ALSO SELECTS PERSONAL ACCIDENT BENEFIT) Name Address Relationship..... Name Address Relationship Does the applicant or any of the persons covered have health, life or accident insurance with other insurance companies? 2. Have the applicants or persons covered ever had an application rejected or a policy cancelled, rated and restricted by other insurance companies?. 3. Has the applicant, spouse or child ever undergone a surgical procedure or investigative procedure or been hospitalized or had an accident? If yes, please give details including the nature of the diseases, disorder, condition or illness, the date of onset and the date of recovery, name of the doctor, the place of treatment and further treatment plan, if any. 4. Has the applicant, spouse or child ever been advised to have a surgical operation or investigative procedure which has not yet been performed? If yes, please give details including the name and address of the doctor making the recommendation. 5. During the past 5 years, has the applicant, spouse or child ever consulted a doctor and/or been prescribed any drugs or medication? If yes, please give details of the reason for the consultation and the names of any drugs you or a member of your family have been or are currently taking. 6. During the past 5 years, has the applicant, spouse or child ever had any tests done such as x-ray, ultrasound, CT scan, MRI scan, biopsy, electrocardiogram, blood or urine test? If yes, please give details including date(s), the reason for the tests and place where the tests took place. 7. Is the applicant, spouse or child currently suffering from any symptoms (pain, lumps, bleeding etc) for which you have not yet consulted a doctor? No Yes If yes, please give details. F-CM-01 Rev.4 Effective date 01/06/05 1
2 Please indicate below whether you have ever suffered from or had treatment for the following diseases, symptoms and conditions. It is important that you tell us about any known or suspected medical conditions and symptoms, even if you have not yet consulted a doctor about them. If you do not give us all the relevant information now, it could effect payment of your claims later on. Chronic headache Migraine headache Systems / Diseases Yes No Additional details Numbness, paresthesis, weakness of extremities Eye disorder and abnormalities Ear disorder and abnormalities Nose disorder and abnormalities Allergy (exclude drug allergy, food allergy) Asthma Respiratory disorders Peptic ulcer Chronic abdominal pain Digestion abnormality and dyspeasia Abnormal stool ie: bloody stool, bowel habit change Hemorrhoids Gall bladder disorder ie: gall stones, cholecystitis Jaundice and cirrhosis Kidney and urinary tract disorder ie: stone, trouble passing water, bloody urine Prostate gland abnormalities (male only) Thyroid disorder Sex Hormonal abnormalities Cardiovascular and blood vessel disorder Blood disorder (including anemia, white blood cell and platelet) Hypertension Bone, joint and muscular disorder ie: chronic arthritis, gouty arthritis Chronic back pain or off and on back pain Non-malignant tumor, mass or cyst Malignant tumor or mass, cancer Bodily deformity Diabetes mellitus (DM) Hypercholesterol or hyperlipidemia Breast disorder and abnormalities Uterus, ovarian tubes and ovarian disorder (female only) Menstruation disorder (female only) Are you currently suffering from any other disease or injuries? Are you currently taking any medication or any treatment regularly? In the event that you have ticked yes to any of the above and you have received treatment, you are requested to provide more information below: Please state the name of the physician, hospital or clinic together with the address which the applicant or persons covered use regularly. (If you are a non-thai national please give the name and address of the doctor at your last place of residence or your regular family doctor.) F-CM-01 Rev.4 Effective date 01/06/05 2
3 All the above statements are true and complete to the best of my knowledge and belief and I understand that the Company, believing them to be such, will rely on them. I, do hereby, appoint BUPA Health Insurance (Thailand) Ltd as the Attorney-in-fact to request a photocopy or any kinds of information of my health record or health conditions from any physician or health care provider or any organisation on my behalf until completion. A photocopy of this statement shall be as effective and valid as the original. Signature of Applicant..Date.. (and on behalf of children) Signature of Spouse..Date.. WARNING BY INSURANCE DEPARTMENT, MINISTRY OF COMMERCE The applicant must truthfully answer all questions. Any concealment or misrepresentation of the truth may result in the insurance company refusing to honor insurance claims, as per clause 865 of the Civil and Commercial Code. If you have any queries regarding this Insurance Policy, please contact BUPA Health Insurance (Thailand) Ltd, telephone or the Office of the Insurance Commissioner, telephone I hereby confirm that this applicant is the employee of the company. (Valid only upon Company Stamp and authorized signature) Employer Authorised signature.. Position For BUPA Health Insurance Use Only : Medical Confidentiality Note: The confidentiality of your information is of the utmost importance to BUPA. Your medical information will only be discussed with those involved with your treatment and care, including your doctor and clinical persons involved in your treatment or called upon to give a second opinion, and if applicable to any person or organisation meeting your treatment expenses or their agents. If you have any concerns about the confidentiality of your information, please contact the Managing Director at ext 501. F-CM-01 Rev.4 Effective date 01/06/05 3
4 Dear Mr. / Ms. Ref No. Additional information This section applies if you have indicated "Yes". If you are unsure whether any details are relevant, you must include them. Health Declaration No. The name of the illness or medical problem. Where applicable, please state the area of the body affected (eg right leg, left eye). When did the symptoms start? When was treatment completed? What treatment did you receive and when (please include dates, names and details of medications)? What was the outcome of the treatment? ongoing complete recovery recurrent likely to recur Underwriter. Yours truly, All the above statements are true.. Signature. Date In case of you give your health information by telephone and Bupa staff fill this form, you agreed that all information are relevant. If there is no enough space, you can tick / in ( ) and use other paper to fill this form. WARNING: By Insurance Department, Ministry of Commerce The application must truthfully answer all questions. Any concealment or misrepresentation of the truth may result in the insurance company refusing to honor insurance claims, as per clause 865 of the Civil and Commercial Code. F-CM-01 Rev.4 Effective date 01/06/05 4
5 CHOOSE YOUR PLAN (Please mark X ) Plan 6 10,886 Plan 7, Plan 8, PLEASE COMPLETE & ATTACH (Please mark X ) Copy of front page of Passport attached Copy of your Social security card OR Copy of your work permit or social security OR If no work permit / social security card please indicate reason Yes or No Yes or No Spouse of permit holder Student Recently arrived in Thailand Recently joined the association Other Signature Date (DD MM YYYY) / / F-CM-01 Rev.4 Effective date 01/06/05 5
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Personal Training Health Screening Questionnaire Personal Information Today s date: Title: Dr. Mr. Mrs. Ms. Name: / Birth date: Last name First name Age: Address: Phone: (home) City: Phone: (work) Province:
Please fill out forms, sign where needed and bring with you to your first visit. If you have any questions please call the office at 212-751-8300.
Welcome to Manhattan Sports Medicine and the office of Dr. Kyle Worell. Before we get started please see all forms below: Personal History (Intake) Informed Consent Payments HIPPA Please fill out forms,
Otis R. Washington, D.D.S., M.S., P.A. Diplomate of the American Board of Periodontology
Otis R. Washington, D.D.S., M.S., P.A. Diplomate of the American Board of Periodontology 2310 Myron Drive Raleigh, North Carolina 27607 P: (919) 782-9536 F: (855) 787-8025 Name: SSN: Date of Birth (mmddyy):
City: State: Zip: City: State: Zip: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: City: State: Zip:
Name: Mailing Address: First M.I. Last Today s Date: Physical Address: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: Employer: Occupation: Employer s Address: Work
Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL 60030 Phone: 847-247-7200 Fax: 847-247-4340
Medical Registration Form (Page 1) Welcome to our Office: By completing this patient information form, you will help us to serve you more efficiently. Should you have any questions concerning our professional
PELED PLASTIC SURGERY HEADACHE HISTORY FORM
HEADACHE HISTORY FORM IF THIS IS YOUR FIRST VISIT, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone: Cell Phone:
NEW PATIENT HISTORY QUESTIONNAIRE. Physician Initials Date PATIENT INFORMATION
NEW PATIENT HISTORY QUESTIONNAIRE Physician Initials Date PATIENT INFORMATION JHH# DOB# AGE HOME PH CELL PH DAY PH EMAIL Who is your REFERRING PHYSICIAN? (The doctor who referred you to Johns Hopkins Neurology.)
S.G.E.U. HEALTH AND WELFARE TRUST PORTAPLAN
S.G.E.U. HEALTH AND WELFARE TRUST PORTAPLAN TERM LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT YOUNG ADULT SECURITY INSURANCE DEPENDENT LIFE INSURANCE S.G.E.U. Health and Welfare Trust Dear SGEU Members
APPLICATION FOR QUICK ISSUE CRITICAL ILLNESS
APPLICATION FOR QUICK ISSUE CRITICAL ILLNESS GENERAL INFORMATION - INSURED LIFE INSURED (PRINT) DATE OF BIRTH AGE SEX M F LIFE INSURED ADDRESS NUMBER, STREET, CITY, PROVINCE DAY MONTH YEAR OCCUPATION PLACE
Voluntary Benefits Employee Enrollment and Change Form
LifeMap Assurance Company TM P.O. Box 1271, MS E-3A Portland, OR 97207-1271 (503) 721-7161 (800) 794-5390 Voluntary Benefits Employee Enrollment and Change Form For residents of Oregon and Washington,
FAIRBANKS PHYSICAL THERAPY
REGISTRATION PAPERWORK CHECKLIST If you wish, you can save time and simplify the registration process by completing the registration paperwork before you arrive. This checklist will help make sure you
WORKER S COMPENSATION HISTORY FORM NAME (Last, First, Middle Initial) Height Weight
341 Magnolia Avenue, Suite 101 28078 Baxter Road, Suite 330 Corona, CA 92879 Murrieta, CA 92563 (951) 735-6060 (951) 735-4510 Fax (951) 677-2157 www.ctoamg.com WORKER S COMPENSATION HISTORY FORM NAME (Last,
LAWRENCE J. FINKEL, M.D., P.C. 360 CHURCH STREET WARRENTON, VA 20186 (540) 347-2020 PHONE (540) 341-7980 FAX www.finkelderm.net
360 CHURCH STREET WARRENTON, VA 20186 (540) 347-2020 PHONE (540) 341-7980 FAX www.finkelderm.net Dear Patient: Welcome to our Practice. We have you scheduled for your first appointment at our office on