1515 Saint Joseph Avenue P.O.

Box 8000 Marshfield, WI 54449-8000 1-800-472-2363 or 715-221-9555 TTY 1-877-727-2232 or 715-221-9898

Insurance Underwriting Information

Applicant MHN

List the names of anyone applying for coverage who receives primary care from Marshfield Clinic or their regional centers. If primary care is received from these centers, you will not need to complete the Attending Physicians Statement on the reverse side or obtain any medical record information. Marshfield Clinic Centers Athens Bloomer Cadott Chippewa Colby/ Abbotsford Cornell Cumberland Eagle River Eau Claire Elk Mound Greenwood Ladysmith
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Lake Country Lake Hallie Loyal Marshfield Menomonie Mercer Merrill Minocqua Mosinee Oakwood Osseo Park Falls

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Phillips Radisson Rhinelander Rice Lake Riverview (Eau Claire) Stettin Stratford Wausau Weston Wisconsin Rapids Wittenberg

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If primary care is not received from Marshfield Clinic or one of its regional centers, please follow these instructions: 1. Take the Attending Physicians Statement on the reverse side of this form and the Authorization to Use and Disclose Protected Health Information for Enrollment and Related Purposes form to your primary/family physician or attach a copy of the last 3 years of your medical record. 2. Your physician should complete the Attending Physicians Statement and return it to you along with the Authorization to Use and Disclose Protected Health Information for Enrollment and Related Purposes form. 3. You should then return this form with your application, health statement, etc. in the enclosed envelope to the Membership Department of Security Health Plan. It is your responsibility to provide us with the necessary medical information to process your application. Security Health Plan will pay fees incurred in obtaining this information. Notify us if you receive a bill or if you need to be reimbursed for up-front charges you are requested to pay for your medical information. If you have further questions, please contact our Customer Service Department at 1-800-472-2363 or 715-221-9555. Our office hours are Monday, Wednesday, Thursday and Friday from 7 a.m. to 5:30 p.m. and Tuesday from 8 a.m. to 5:30 p.m.
HP-00044 (04/11) 2003-2011 Security Health Plan of Wisconsin, Inc.

Attending Physicians Statement

RE: his statement or a copy of the last 3 years of the medical record is requested in order to issue T insurance coverage to the person named above. DOB:

t is not necessary to schedule or conduct an examination for the purpose of completing this record. I Your prompt assistance will be greatly appreciated.
Please tell us your knowledge of the following:

Past history and current illness

Significant adult illness

Surgery the patient has undergone

Any psychiatric, chemical dependency, or eating disorder hospitalization

Any abnormal X-ray, lab or EKG findings

Any tobacco use in the past year: Is the applicant pregnant: Medications Current blood pressure

l Yes

l Yes

l No

l No

l Unknown

Current height

Current weight

Recommended hospitalizations, surgeries or treatments being considered or presently requested by the patient

When was the last time you saw this patient?

Physicians signature Facility

HP-00044 (04/11) 2003-2011 Security Health Plan of Wisconsin, Inc.

Date (month/day/year)