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GlobalHealth is not going to provide coverage for Arizona starting January 01, 2023

HEALTH SURVEY

The goal of this survey is to help us understand your health and specific healthcare needs so we can work together to help provide you with the services to reach your health goal(s).

The information submitted in this survey will be used internally by our Care Management Department and may be shared with your Primary Care Physician (PCP) if there are gaps in care that need to be addressed.

Any information provided will not be used against you in any way or impact the services you obtain from the health plan.

Completion and submission of the confidential Health Survey implies consent to its stated use; however, you do have the option to decline completion of this survey.

Member Information

Enter distance in miles

3. CHRONIC HEALTH CONDITIONS HAVE YOU EVER HAD OR BEEN TREATED FOR ANY OF THE FOLLOWING:
4. HEALTH CARE ACCESS AND TREATMENT: Check YES or NO.
5. ACTIVITIES OF DAILY LIVING : Do you need help with any of the following tasks? Check YES or NO.
6. BEHAVIORAL AND SOCIAL: Check YES or NO.
7. MEDICAL TREATMENT / VACCINATIONS:
You have the option to have a Case Manager. This is someone assigned to you to help in further evaluating your care needs and developing a plan to meet them. We encourage you to participate in this valuable health plan benefit, however, if you do not wish to participate, let us know by checking the box below.

IMPORTANT NOTE: If you do not check the box above, it will be indicated that you do want to participate in the GlobalHealth Care Management Program.

 

Thank you for taking the time to complete this Health Survey!