HEALTH STATUS NOTICE: Due to Texas & Federal Legislature, small groups of 1-50 employees must answer medical questions and CAN BE rated for health conditions. Please answer the following to the best of your knowledge:
1.Within the last 24 months have any employees or their dependents to be covered consulted, received treatment, had medication prescribed by a doctor, psychiatrist, psychologist, or other practitioner or been diagnosed for:
Cancer, stroke, diabetes, heart or vascular disease, mental or emotional disorder, muscular or systemic disease (such as arthritis or lupus), alcohol or drug use, liver, kidney, lung or intestinal disorder, infertility, transplant completed or pending, growth disorder, enlarged lymph nodes, or other immune disorder? Within the last 24 months, have any employees or their dependents been diagnosed with AIDS or ARC? (List any medications, dosages, and how many times daily they are taken.)
2. Are any employees or dependents to be covered pregnant, or been advised in the last 12 months that hospitalization, surgery, or treatment is needed or pending?
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