Section Name |
Field Name |
Field and/or Section Description |
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Use Informal Inquiry Application – Part 2 Medical History Supplement – Medical Condition |
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Details / Additional Care Providers, ACORD 784, when more space is required to provide |
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Informal Inquiry Application – Part |
medical condition details and/or additional care providers. |
|
2 Medical History Supplement – |
|
TITLE |
Medical Condition Details / |
IMPORTANT: This form is not filed with any regulator in any jurisdiction. This form |
ACORD 784 (2008/01) |
Additional Care Providers |
cannot become part of an insurance policy. |
IDENTIFICATION SECTION |
Name of Requestor |
Name of agent or broker must be inserted before this form is used. |
PROPOSED INSURED (PI) |
First Name |
First name of the proposed insured. |
PROPOSED INSURED (PI) |
Middle Name |
Middle name of the proposed insured. |
PROPOSED INSURED (PI) |
Last Name |
Last name of the proposed insured. |
PROPOSED INSURED (PI) |
Case ID |
Insert the identification number that identifies the case in the agency system. |
MEDICAL CONDITION |
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|
DETAILS |
Physician First Name |
Provide the physician’s first name. |
MEDICAL CONDITION |
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|
DETAILS |
Physician Last Name |
Provide the physician’s last name. |
MEDICAL CONDITION |
|
|
DETAILS |
Last Treated (mm/dd/yyyy) |
Indicate the date last treated. |
MEDICAL CONDITION |
Reason Last Seen |
Indicate the reason you last saw an additional care provider. Describe the symptoms and |
DETAILS |
(Diagnosis/Symptoms) |
diagnosis, if known. |
MEDICAL CONDITION |
|
|
DETAILS |
Tests – Type, Date Results |
Indicate specific tests and results related to the reason last seen. |
MEDICAL CONDITION |
|
|
DETAILS |
Medical ConditionIdentifier |
Specify Item # from Section 3 or 4. |
MEDICAL CONDITION |
|
|
DETAILS |
Still Under Treatment? |
Indicate whether or not the proposed insured is still under treatment. |
MEDICAL CONDITION |
|
|
DETAILS |
Last Episode (mm/yyyy) |
Indicate the date this condition last occurred. |
MEDICAL CONDITION |
|
Indicate any medication or treatment prescribed, including dosage amount, related to |
DETAILS |
Medication / Treatment / Therapy |
reason last seen. |
|
Additional Information / |
|
MEDICAL CONDITION |
Complications / Activity |
|
DETAILS |
Limitations / Recovery |
Indicate any other information regarding this condition. |
MEDICAL CONDITION |
|
|
DETAILS |
Physician First Name |
Provide the physician’s first name. |
MEDICAL CONDITION |
|
|
DETAILS |
Physician Last Name |
Provide the physician’s last name. |
MEDICAL CONDITION |
|
|
DETAILS |
Last Treated (mm/dd/yyyy) |
Indicate the date last treated. |
MEDICAL CONDITION |
Reason Last Seen |
Indicate the reason you last saw an additional care provider. Describe the symptoms and |
DETAILS |
(Diagnosis/Symptoms) |
diagnosis, if known. |
MEDICAL CONDITION |
|
|
DETAILS |
Tests – Type, Date Results |
Indicate specific tests and results related to the reason last seen. |
MEDICAL CONDITION |
|
|
DETAILS |
Medical Condition Identifier |
Specify Item # from Section 3 or 4. |
MEDICAL CONDITION |
|
|
DETAILS |
Still Under Treatment? |
Indicate whether or not the proposed insured is still under treatment. |
MEDICAL CONDITION |
|
|
DETAILS |
Last Episode (mm/yyyy) |
Indicate the date this condition last occurred. |
MEDICAL CONDITION |
|
Indicate any medication or treatment prescribed, including dosage amount, related to |
DETAILS |
Medication / Treatment / Therapy |
reason last seen. |
|
Additional Information / |
|
MEDICAL CONDITION |
Complications / Activity |
|
DETAILS |
Limitations / Recovery |
Indicate any other information regarding this condition. |
ADDITIONAL CARE |
|
|
PROVIDERS |
Historical Physician First Name |
Provide the physician’s first name. |
ADDITIONAL CARE |
|
|
PROVIDERS |
Physician Last Name |
Provide the physician’s last name. |
ADDITIONAL CARE |
|
|
PROVIDERS |
Facility Name |
Provide the name of thehealth care facility (if applicable) |
ADDITIONAL CARE |
|
Indicate the telephone number of the personal physician or health care facility. Include |
PROVIDERS |
Phone Number |
area code and extension (if applicable) |
ADDITIONAL CARE |
Reason Last Seen |
Indicate the reason you last saw an additional care provider. Describe the symptoms and |
PROVIDERS |
(Diagnosis/Symptoms) |
diagnosis, if known. |
ADDITIONAL CARE |
|
|
PROVIDERS |
Tests – Type, Date Results |
Indicate specific tests and results related to the reason last seen. |
ADDITIONAL CARE |
|
Indicate the address of thepersonal physician or health care facility. Do not use P.O. Box |
PROVIDERS |
Street Address Line 1 |
number. |
ADDITIONAL CARE |
|
|
PROVIDERS |
Line 2 |
Address – Line 2. |
ADDITIONAL CARE PROVIDERS |
City |
Indicate the city of the address. |
ADDITIONAL CARE PROVIDERS |
State |
State of the address. |
ADDITIONAL CARE PROVIDERS |
Zip |
Zip code, postal code, etc. (country dependent) |
ADDITIONAL CARE PROVIDERS |
Date Last Seen |
Indicate the date you last saw aprimary care provider. |
ADDITIONAL CARE PROVIDERS |
Medication / Treatment / Therapy |
Indicate any medication or treatment prescribed, including dosage amount, related to date last seen. |
ADDITIONAL CARE PROVIDERS |
Remarks |
Use this space for any additional remarks. |