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| for help or questions | |||
| Anthem health forms and questionnaires | call 1-866-508-0618 | ||
| When filling out your Individual Health Statement for Anthem health insurance, you will be required to fill out a questionnaire form if you answered "YES" to any of the questions numbers below. Filling these forms out will help you get health insurance with Anthem. | |||
| Check your health statement to see if you answered yes to the question numbers below. | |||
| Application area | Question numbers | Health condition | Questionnaire form required. Click for form. |
| Part C | 1 | Disability | Disability form |
| Part D | 1a | Cardiac/Hypertension | Hypertension form |
| 1a | Heart Murmur/Mitral Valve | Heart murmur / Mitro valve prolapse form | |
| 1b | Tumor/Cyst/Cancer | Tumor/Cyst/Skin Cancer form | |
| 1d | Mental Health | Mental health form | |
| Attention deficit disorder form | |||
| 1e | Seizure/Epilepsy | Seizure/Epilepsy form | |
| 1f | Alcohol /Drug | Alcohol and drug form | |
| 1h | Abnormal Pap Smear | Abnormal pap smear form | |
| Endometriosis form | |||
| 1i | Spinal |
Spinal form | |
| Fibromyalgia | Fibromyalgia form | ||
| Arthritis | Arthritis form | ||
| Gout | Gout form | ||
| 1k | Digestive | Spinal form | |
| Ulcer | Ulcer form | ||
| Colitis / Irritable Bowl Syndrome | Colitis/ Irritable bowl syndrome form | ||
| 1l | Asthma | Asthma Allergy form | |
| 1m | Kidney / Urinary | Kidney/ Urinary disorder form | |
| 1o | Thyroid | Thyroid form | |
| Part E | A | Asthma | Asthma Allergy form |
| C | Chiropractic Care | Spinal form | |
| F | Headaches / Migraines | Migraine form | |
| I | Skin Problems / Allergies | Allergy form | |
| Other | Newborn | Newborn form | |
| Domestic Partner | Domestic partner form | ||
| Z 4-18-2008 | |||
| For help or questions call 1-866-508-0618 | Back to Anthem insurance | ||