Go to ConnectiCare Insurance |
 |
||
| For help or questions? | |||
| Additional Health Questionnaires | Call 1-866-508-0618 | ||
| When filling out your Individual Health Statement for Connecticare 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 may help you get health insurance with Connecticare. Please call and send forms with your application to Creative Health Insurance LLC, PO Box 2048 Manchester, Ct 06045. | |||
| 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 2 | 1 | Headaches/Migraines |
|
| Seizures/Epilepsy | Seizure/Epilepsy Form | ||
| 2 | Heart Murmur/Mitral Valve | Heart Murmur / Mitro Valve Prolapse Form | |
| 3 | High Blood Pressure | Hypertension Form | |
| 4 | Asthma / Allergies | Respiratory Form | |
| 5 | Gastorintestinal Problems | Gastrointestinal Problems | |
| 6 | Urinary / Prostate/ | Gynecological Services | |
| Abnormal Pap Smear | Urinary/Prostate Disorder Form | ||
| 7, 8 | Reproductive system | Gynecological Services | |
| 9 | Musculosketal pain | Back/Neck Pain Form | |
| Musculoskeletal Form | |||
| 10 | Endocrine/Metabolic/Thyroid | Thyroid Form | |
| 11, 12, 17 | Tumor/Cyst/Skin Cancer | Tumor/Cyst/Skin Cancer Form | |
| 14 | Nervous/Mental/Emotional Behaviors |
Alcohol & Drug Form | |
| Mental Health Form | |||
| Miscellaneous | Forms | Motor Vehicle Accident | Motor Vehicle Accident Form |
| General Health Form | General Health Form | ||
| Domestic Partner Form | Domestic Partner Form | ||
| Z - 07/31/2008 | |||