Health Statements

Health Statements, also known as Universal/Uniform Medical Appraisal Forms, are used by insurance companies to assess the health of individuals. They are completed by employees of an employer group that is seeking health insurance quotes. The health statements are evaluated by the health insurance company to assess risk, thus pricing the group's premiums accordingly.

The Health Statement (Interactive PDF) must be completed by each participating employee and employees who will meet your eligibility requirements by the effective date of the new plan. It is important to maintain the confidentiality of the employees health information.

(Interactive PDF) - An interactive PDF is an electronic form that allows you to type directly into it and it will appear on the form when printed. When you're finished, print the form, sign and date it and submit it to EBSC at your convenience. The fax number is (505) 821-6488. Should you have concerns faxing it, feel free to place it in a sealed envelope and turn it in to your employer's HR Department or the office manager. We can then pick them up or you can mail them to us. If you have any questions or problems using this form, please call or e-mail EBSC: 821-6477 | info@ebsc.net.

Why Do I Need To Provide A Statement Of My Health?

The federal government has required that health plans offer coverage to all small groups regardless of their medical conditions.

The State of New Mexico, who is charged with regulating insurance providers, has step in with their own requirements on how much a plan can "rate-up" a group with medical conditions.

This is why we need to have each employee carefully complete a detailed health statement.