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    Filled PHQ Example

    Uploaded by

    Mitchell Bigley
    John G. Dentist is being enrolled in health insurance coverage through his employer, Corporate Solutions Incorporated, with an effective date of July 1, 2017. He was hired on February 4, 2016. John lives in San Antonio, Texas with his wife Jennifer and two children, Thomas and Madeline. John is selecting the $1500 deductible health insurance plan and does not use tobacco.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Filled PHQ Example

    Uploaded by

    Mitchell Bigley
    35 views4 pages
    John G. Dentist is being enrolled in health insurance coverage through his employer, Corporate Solutions Incorporated, with an effective date of July 1, 2017. He was hired on February 4, 2016. John lives in San Antonio, Texas with his wife Jennifer and two children, Thomas and Madeline. John is selecting the $1500 deductible health insurance plan and does not use tobacco.

    Original Description:

    Use this as a guide to fill out your own PHQ.

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    John G. Dentist is being enrolled in health insurance coverage through his employer, Corporate Solutions Incorporated, with an effective date of July 1, 2017. He was hired on February 4, 2016. John lives in San Antonio, Texas with his wife Jennifer and two children, Thomas and Madeline. John is selecting the $1500 deductible health insurance plan and does not use tobacco.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    35 views4 pages

    Filled PHQ Example

    Uploaded by

    Mitchell Bigley
    John G. Dentist is being enrolled in health insurance coverage through his employer, Corporate Solutions Incorporated, with an effective date of July 1, 2017. He was hired on February 4, 2016. John lives in San Antonio, Texas with his wife Jennifer and two children, Thomas and Madeline. John is selecting the $1500 deductible health insurance plan and does not use tobacco.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    Employer Information

    Employer Name: Date of Hire: Effective Date of Coverage:


    Corporate Solutions Incorporated 02/04/2016 07/01/2017
    Employee Information
    Last name First Name Middle Initial Date of Birth Social Security#
    Dentist John G 04/05/1981 123-45-6789
    Home Mailing Address Street Apt# City State Zip Code
    123 Apple Street N/A San Antonio TX 78216
    Home Phone# E-Mail Address Gender Height Weight Tobacco User
    123-456-7890 [email protected] Male D Yes ,grNo
    - 6'0" 1751bs
    Plan Selection (if applicable): Marital Status: D Single Married (date: 08/13/2002 ) D Divorced (date: )
    $1500 Deductible Plan D Separated (date: ) D Widowed (date: )
    If Applying for Dependent Coverage, Complete Section Below for all Dependents to be Covered:

    First Name Last Name Step- Gender Date of Height Weight Tobacco Social Security
    & Middle Initial (if different from Child Birth User Number
    applicant) (Yes or No)
    Sp Jennifer A. N/A N/A Female 07/22/1984 5' 7" 1301bs No 176-76-2692
    Ch1 Thomas S. N/A No Male 12/16/2004 5' 6" 1221bs No 792-82-8746
    Ch2 Madeline T. N/A No Female 04/26/2014 31.4" 261bs No 916-472-9052
    Ch3
    Ch4

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