Secure HIPAA Chronic Condition Form

Full Name

Phone *

Email

The questions below will help me see if we can get you qualified for a chronic condition plan.

Make sure to say YES to anything that applies to you.

You can choose no, or skip questions that do not apply to you.

If you choose yes anywhere, please add the doctor's name and phone number in the same spot. Also add medication. (don't worry about the spelling, I'll figure it out.)

1.) Clinical qualifying questions for diabetes

Have you ever been told that you have high blood sugar or diabetes?

Yes

No

Have you ever or do you currently measure/monitor your blood sugar?

Yes

No

Have you been prescribed or do you take insulin or an oral medication that’s supposed to lower your blood sugar?

Yes

No

If you answered yes to any diabetes questions, please list the medications you take for diabetes.

If you answered yes to any diabetes questions, please enter the name and phone for the doctor who treats you for diabetes.

2.) Clinical qualifying questions for cardiovascular disorder

Do you have a problem with your heart, had a heart attack, or have you been told that you had a heart attack?

Yes

No

Do you have a problem with your circulation or have you been told that you have problems with your circulation?

Yes

No

Do you have pain in your legs when you walk that gets better when you stop and rest?

Yes

No

If you answered yes to any cardiovascular disorder questions, please list medications you take for cardiovascular disorders.

If you answered yes to any cardiovascular disorder questions, please enter the name and phone for the doctor who treats you for cardiovascular disorders.

3.) Clinical qualifying questions for chronic heart failure

Have you ever been told you have heart failure, or congestive heart failure?

Yes

No

Have you ever been told you have fluid in your lungs?

Yes

No

Have you ever been told you have swelling in your legs due to your heart?

Yes

No

If you answered yes to any of the questions for chronic heart failure, please list medications you take for heart failure.

If you answered yes to any of the questions for chronic heart failure, please enter the name and phone for the doctor who treats you for heart failure.

4.) Clinical qualifying questions for chronic lung disorder (CLD)

Do you have any chronic breathing problems?

Yes

No

Have you ever been told you have a lung problem such as asthma, chronic bronchitis, chronic obstructive pulmonary disease (COPD), cystic fibrosis, emphysema, pulmonary fibrosis, and pulmonary hypertension, scarring in the lung, or high pressure in the lungs?

Yes

No

Do you use inhalers or other medicines for your breathing more than 3 times per week?

Yes

No

If you answered yes to any of the questions for chronic lung disorders, please list medications you take for lung disorders

If you answered yes to any of the questions for chronic lung disorders, please enter the name and phone for the doctor who treats you for lung disorders.

5.) Clinical qualifying questions for chronic kidney disorder (CKD)

Have you been told you have stage 3 or higher chronic kidney disease?

Yes

No

If you answered yes to the question for chronic kidney disease, please list medications you take for lung disorders (copy)

If you answered yes to the questionsfor chronic kidney disease, please enter the name and phone for the doctor who treats you for chronic kidney disease.

Privacy Policy | Terms of Service