Health Benefit Alliance Partnership Program
Group Health Questionnaire
This Group Health Questionnaire is utilized to assist in the assessment of the risk associated with your group and whether it is a good fit for the HBA Partnership Program.
You acknowledge that you will answer these questions truthfully, completely, following reasonable commercial effort, and to the best of your knowledge. This form may be used and shared with all vendors of the HBA Program. This form will also be shared with other vendors outside of the HBA Program that service the group health plans implemented for your group through the HBA Program, including but not limited to insurance and/or reinsurance carriers. To the extent that this form is relied upon by these vendors, false or misleading statements could adversely impact the services provided as well as trigger termination rights. To the extent this form is separately used or analyzed by an insurance company, additional legal or contractual consequences, including, but not limited to, a loss of coverage or denial of coverage may occur.
Group Health Questionnaire Appendix
Please use this page to provide more detail to responses in the Group Health Questionnaire which requested further explanation.