STATEMENT OF HEALTH - Free Forms Online 2025

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The document is a health statement form for employees applying for insurance coverage, specifically for employee-only plans. It requires personal information about the insured and their dependents, along with a series of health-related questions to assess medical history and any existing conditions. The form also includes an authorization for the insurance company to obtain medical information.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your full name, birth date, height, weight, and sex in the designated fields for the insured. Ensure accuracy as this information is crucial for your health statement.
If applicable, fill out the spouse and child(ren) sections with their respective details. Remember that dependents' information is not required when applying for employee-only coverage.
Answer the health-related questions regarding past medical history by selecting 'YES' or 'NO'. If you answer 'YES' to any question (except question e), provide detailed information in the space provided below.
In the section for additional details, include names of individuals with illnesses, nature of their conditions, dates of treatment, and any remaining effects. This ensures comprehensive disclosure.
Finally, review all entered information for accuracy before signing and dating the form at the bottom. Your signature confirms that all information is true to the best of your knowledge.

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1996	4.8 Satisfied (271 Votes)

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Where can I get a statement of good health?

Obtain the form: You can usually get a statement of good health form from your insurance company or employer.

What do you put on a medical form?

What are the most important details in your medical history? chronic or new symptoms and conditions. past surgeries. family medical history. insurance information. current prescription and over-the counter medicines, supplements, vitamins, and any herbal remedies or complementary medicines you use. medication allergies.

Who fills out a statement of health form?

The Proposed Insured / Applicant (if over the age of 18) must sign and date the Statement of Health and Authorization forms. If the Proposed Insured / Applicant is under the age of 18, his/her personal representative must sign and date the Authorization.

How do I fill out a medical request form?

How to fill out a health or medical record release form Patient information. Whose health records do you want? Clinic, hospital, care provider. Date of Services. Information to be released. Receiving party or destination of records. Purpose of release. Expiration date or duration of consent. Release instructions.

Can you fill out medical forms online?

Online Medical Forms are patient intake forms that can be conveniently completed online rather than on paper in the medical office.

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Can you fill out a HIPAA form online?

To obtain a HIPAA release form, you can request one directly from your healthcare provider or their administrative office. Many healthcare organizations also provide digital versions of HIPAA release forms that you can fill out and submit online.

What is an example of a statement of good health?

(1) I have continued in good health. (2) I have not made an application for insurance, which has been declined, postponed, or modified. (3) I have not consulted or been examined by a physician or practitioner.

How does IntakeQ work?

With IntakeQ, patients can submit forms securely prior to their appointments. This streamlines the whole intake process as we can get each patient entered into our EMR system, verify their insurance and identify any additional forms that might be required before they come in.

STATEMENT OF HEALTH - Free Forms Online 2025

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How to use or fill out STATEMENT OF HEALTH - Free Forms Online

See more STATEMENT OF HEALTH - Free Forms Online versions

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Got questions?

Where can I get a statement of good health?

What do you put on a medical form?

Who fills out a statement of health form?

How do I fill out a medical request form?

Can you fill out medical forms online?

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Can you fill out a HIPAA form online?

What is an example of a statement of good health?

How does IntakeQ work?

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