Medical History Statement - Escambia County Board of County Commissioners, 12985 754403 2026

1. Click ‘Get Form’ to open the Medical History Statement in the editor.
2. Begin by filling out the Member/Employee Information section. Enter your name, group number, and select who is applying (Member/Employee, Spouse, or Child). Provide your birthdate and date hired.
3. Next, complete the Applicant Information section. Fill in the applicant's name, address, email, sex, birthdate, and residency status. Ensure you include social security numbers and contact information.
4. In the Application Information section, indicate the type of application (Initial, Increase in Coverage, Late Application) and specify the coverage amount requested.
5. Proceed to answer all Medical History Statement questions. Check 'Yes' or 'No' for each question and provide details for any 'Yes' answers. Use a separate sheet if necessary.
6. Finally, review the Acknowledgment and Authorization section carefully before signing and dating at the bottom of page 2.

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