Healthy Indiana Plan

First name:			Last Name:
Address:			City:
State:			Zip:
Phone: ex: 555-123-3928			Email:
Best time to call:

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Gender:		Date of Birth:

Height:		Weight:
Ft In		Lbs

Currently insured? Current carrier:	Yes No
Current medications:
Are you a smoker?	Yes No
Are you a full-time student?	Yes No
Coverage to begin:
Pre-existing conditions?	Yes No aneurysm cancer depression diabetes drug/alcohol emphysema heart disease HIV/AIDS high blood pressure kidney disease MS paralysis pregnancy stroke