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UHG Physical Examination Disclosure Form 05-01-2017

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lani santiago
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35 views2 pages

UHG Physical Examination Disclosure Form 05-01-2017

Uploaded by

lani santiago
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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PRE-EMPLOYMENT EXAM ANNUAL PHYSICAL EXAM

PRE-EXISTING CONDITIONS DISCLOSURE FORM page 1 of 2

With this instrument, I hereby declare submission to the prerequisite Routine Medical Examination and agree to abide by the
provisions around/related to my application/employment to Optum Global Solutions (Philippines), Inc. To which I commit,
agree and undertake to be bound by the conditions thereof.
I fully understand that there shall be no coverage in effect for any incurred charges beyond the standard pre-employment/
annual physical examination package, and should any additional tests are required due to findings or advent of a high-index of
suspicion for any condition(s). Hence, Optum Global Solutions (Philippines), Inc. shall not be liable for any medical claims
during the time between the time of signing this form, and the effective date to which my benefits as an employee is applicable;
other than the components of this routine medical examination.
I hereby agree and undertake as my obligation to participate in full with the proceedings of this routine medical examination,
to disclose in full, and to the best of my knowledge any pertinent information with regard to my health status and history.
I further submit to the rule that any form of intentional non-disclosure or misrepresentation on provided medical history and/or
conditions that I may or may not harbor, are grounds that may adversely affect my application/employment.
PART 1 APPLICANT INFORMATION
NAME OF APPLICANT: LAST, FIRST, M.I. BDATE: M.D.Y. AGE CIVIL STATUS GENDER

PERMANENT RESIDENTIAL ADDRESS HOME PHONE# MOBILE PHONE#

TRANSIENT RESIDENTIAL ADDRESS EMAIL ADDRESS

PART 2.1 STATEMENT OF HEALTH


I hereby clearly understand and agree that failure to declare illnesses in the following questions may adversely
affect may application/employment status.
1. Have you had prior history or complained of any untoward symptoms, received medical advice or
professionally rendered treatment, or was confined due to diseases or conditions of: YES NO
1.1. The brain or nervous system – such as loss of consciousness, dizziness, headaches, seizure disorder,
paralysis, mental illness, retardation or stroke?
1.2. The cardiovascular system – such as heart disease, rheumatic fever, palpitation, shortness of breath, chest
pain? High abnormal blood pressure, heart murmur, etc.?
1.3. The peripheral vascular disease – such as varicose veins, phlebitis, aneurysm, arthritis, embolism, etc?
1.4. The digestive system – such as ulcer, gall bladder disorder, liver disease, colitis, chronic diarrhea, fistula?
Hemorrhoids, colon or intestinal disorder, hernia, malabsorption and pancreatitis?
1.5. The genito-urinary system – such as renal colic, stone, bladder or kidney disorder, stricture, prostate
disorder? Syphilis or venereal disease, etc.?
Chronic (occurring for more than 3-months) and/or Recurrent/-ing
(occurring every 2-weeks) Urinary Tract Infection?
1.6. The metabolic system – such as diabetes, gout, thyroid or adrenal etc. and immune system disorders?
1.7. The musculo-skeletal system – such as back sprain, neck or back disorder, arthritis, fractures, slipped disc,
dislocation, joint problems, etc.?
1.8. The respiratory tract – such as asthma, coughing of blood, allergies, emphysema?
1.9. The eyes, ears, nose or throat?
1.10. Any skin disorders/lesions, itchiness, psoriasis, keratosis, herpes, etc.?
1.11. Unusual weight loss, fatigue, enlarged lymph nodes, any tumor/growth or cancer?
1.12. Alcoholism or drug dependency?

2. Have you ever had any hospitalization or surgery?


If YES, please specify? ________________

page 2 of 2

PART 2.2 STATEMENT OF HEALTH DETAILS


For “YES” answers in PART 2.1., please complete the following information. You may use a separate sheet for more details or attached pertinent documents related to the declarations.
QUESTION NAME OF ATTENDING DOCTOR SHORT DESCRIPTION
NO. DIAGNOSIS / CONDITION INCLUSIVE DATES
and HOSPITAL OF TREATMENT DONE
PART 2.3 HEALTH COVERAGE
YES NO
1. Where you examined, treated or hospitalized that was covered as a member of any Insurance/HMO?
If YES, please elaborate:
2. Have you filed any claim for reimbursement for medical services with any Insurance/HMO?
If YES, indicate status of claim.
3. Have you ever been rejected for membership in any medical insurance/HMO? Or was offered insurance at
higher ( rated up ) premiums? If YES, please specify:

PART 3 AUTHORIZATION FOR DISCLOSURE OF PERSONAL INFORMATION


I hereby authorize the healthcare facility, physician, and/or other healthcare professional duly assigned by Optum
Global Solutions (Philippines), Inc. to process and obtain information on my current health status, any illness, injury or
condition that I have had at any time in the past, or may be expected in the immediate future, and to transfer such information
to Optum Global Solutions (Philippines), Inc.. I understand that this information is collected for the processing of my application
and evaluation for any probable impact my current health status will have on my employment, and vice-versa.
I also understand that this information will be retained for a maximum period of three (3) years, unless I object to such retention.
PART 4 VALIDATION OF EXAMINING PHYSICIAN
I hereby validate that the patient who's name appears on this form have fully complied and gone through the motions required
to complete a thorough routine medical examination. And that the medical history herein declared have been gone through
item-by-item, with due probing as required should a high-index of suspicion for any condition is warranted.

I have read the conditions of application and authorization stated above and fully understand and agree to them.

SIGNATURE OVER PRINTED NAME OF APPLICANT SIGNATURE OVER PRINTED NAME OF ATTENDING/EXAMINING PHYSICIAN

DATE DATE

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