CHOLESTEROL AND HIGH

BLOOD PRESSURE MEDICAL

QUESTIONNAIRE
IMPORTANT INFORMATION

Please complete this form clearly in BLOCK CAPITALS.

The purpose of this form is to enable us to fairly underwrite the policy you wish to take out from us. It is important
that you give us complete and accurate information as we will rely on this when agreeing to the terms and conditions
of a plan.

The questions in this form and any other information we ask for are essential for us to underwrite and administer your
plan. You must tell us about all material facts we have asked for before we can accept an application or renew the plan. If
you do not tell us all material facts we have asked for or misrepresent any material facts, it may affect your rights or your
dependants’ rights under the plan. Failure to answer all questions fully and honestly may invalidate your insurance. A copy
of the completed application form can be supplied on request, but you should keep a record of all information you supply
to us, including copies of all letters.

We must receive all outstanding information before we can process your application. If you do not complete this form in full
it will cause delays.

1 APPLICANT'S PERSONAL DETAILS

Membership Number - -

Title First name

Other initials Family name

Date of birth D D M M Y Y Date form completed D D M M Y Y

2 PLEASE ANSWER THE FOLLOWING QUESTIONS

1. Which of these conditions are you receiving treatment for? Please tick as appropriate:

a. High blood pressure Date of diagnosis D D M M Y Y

b. High cholesterol Date of diagnosis D D M M Y Y

2. How was your high blood pressure and/or high cholesterol discovered?

a. Routine check

b. During an illness (please specify)

c. Other (please specify)

3. Are you under regular follow-up for these conditions? Y N

4. How often do you see your doctor/practice nurse?

5. Do you smoke? Y N

6. What treatment has been prescribed by your doctor?

a. Diet only

b. Medication
 If you have been prescribed medication, please give details of the medication you are taking:

Name of medication

Dosage

Taken how often?

Cholesterol level at time of diagnosis:

Blood pressure level at time of diagnosis:

Please provide as many Blood Pressure/Cholesterol level readings as you can:

Date Blood Pressure Cholesterol level

1 year ago /

3 months ago /

Latest /

Other /

Other /

Other /

3 DATA PROTECTION NOTICE

Purpose:
Personal data collected on you and, where appropriate, your
family, will be used by Bupa Global to process your claims,
administer your policy and may be used to detect and prevent
fraud or improper claims.
Confidentiality:
The confidentiality of patient and member information is of
paramount concern to Bupa Global. To this end, Bupa Global
fully comply with UK Data Protection Legislation and Medical
Confidentiality Guidelines. Bupa sometimes uses third parties
to process data on its behalf. Such processing, which may be
undertaken outside the European Economic Area, is subject to
contractual restrictions with regard to confidentiality and security
in addition to the obligations imposed by the Data Protection Act.
Member details:
All membership documents and confirmation of how we have
dealt with any claim you may make will be sent to the principal
member.
Telephone calls:
In the interest of continuously improving our service to members,
your call will be recorded and may be monitored.
Research:
Anonymised or aggregated data may be used by Bupa Global, or
disclosed to others, for research or statistical purposes.
Fraud:
Information may be disclosed to others with a view to preventing
fraudulent or improper claims.

Medical Information: Names and Addresses:

Medical information will be kept confidential. It will only be
disclosed to those involved with your treatment or care,
including your General Practitioner/Primary Health Physician, or
to their agents, and, if applicable, to any person or organisation
who may be responsible for meeting your treatment expenses,
or their agents. Claims information may also be shared with
appointed third parties involved in the management and
handling of your claim. Claims information may be discussed
with the Bupa Global Agent/Adviser where you have requested
the Adviser to assist you.
Bupa Global does not make the names and addresses of
members or patients available to other organisations.
Keeping you informed:
Bupa Global would, on occasion, like to keep you informed of
Bupa Global products and services which it considers may be of
interest to you.
Contact Address:
If you do not wish to receive information about Bupa Global’s
products and services, or have any other Data Protection
queries please write to the Head of Information Governance, at
Bupa House, 15-19 Bloomsbury Way, London WC1A 2BA or at
DataProtection@Bupa.com.

4 DECLARATION
I declare that all the information given for the purposes of receiving my quotation and being covered is true and complete.
BIN-BWHO-BPHC-1407v1.2

Applicant name Applicant Signature Date