Bright Sky Group of Services

Employee Medical History Questionnaire For Any Person Electing MVP Option


Please provide the following information for yourself as well as for any family members on whose behalf you are electing medical coverage:

Spouse Last Name: | Spouse First Name: | Spouse DOB:  

Child #1 Last Name: | Child #1 First Name: | Child #1 DOB:  

Child #2 Last Name: | Child #2 First Name: | Child #2 DOB:  

Child #3 Last Name: | Child #3 First Name: | Child #3 DOB:  

On behalf of yourself and each of your family members listed above, please respond to each of the questions listed below. When you have finished answering all questions, please sign and date the bottom of this form.

1. Are you or any of your family members listed above currently confined or have you been confined to a hospital/other institution in the twelve months prior to the signing of this form?:
1a. Please provide the details, including family member name, date of treatment/event, medical and RX services received and/or planned, treatment plan, prognosis and approximate cost :  

2. Have you or any of your family members listed above had surgery or other procedure(s) on an outpatient basis in the twelve months prior to the signing of this form?:
2a. Please provide the details, including family member name, date of treatment/event, medical and RX services received and/or planned, treatment plan, prognosis and approximate cost :

3. Are you or any of your family scheduled for or planning on having any inpatient or outpatient surgeries or other procedures in the next twelve months following the signing of this form?:
3a. Please provide the details, including family member name, date of treatment/event, medical and RX services received and/or planned, treatment plan, prognosis and approximate cost.:

4. Are you or any of your family members listed currently unable to work, attend school, perform daily tasks, etc. due to illness /injury?:
4a. Please provide the details, including family member name, date of treatment/event, medical and RX services received and/or planned, treatment plan, prognosis and approximate cost.:

5. Are you or any of your family members listed above on COBRA? Have you or any of your family members recently received or are you/they expecting to receive a COBRA notification letter?:
5a. Please provide the details, including family member name, date of treatment/event, medical and RX services received and/or planned, treatment plan, prognosis and approximate cost.:

6. Have you or any of your family members listed above been diagnosed with and/or received treatment for any of the diagnoses listed on the attached list?:
6a. Please provide the details, including family member name, date of treatment/event, medical and RX services received and/or planned, treatment plan, prognosis and approximate cost.:

Leave this empty:

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Signature Certificate
Document name: Employee Medical History Questionnaire For Any Person Electing MVP Option
lock iconUnique Document ID: 5b3dc365a9338df36237e91a17bc4065441227e7
Timestamp Audit
January 18, 2021 10:33 pm CDTEmployee Medical History Questionnaire For Any Person Electing MVP Option Uploaded by National Star Services - megan@meganforddesign.com IP 98.213.216.126