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ALCOHOL & DRUG QUESTIONNAIRE
(Complete all questions)
Name of person treated/relationship to applicant: 1. Are you currently using or have you ever used the following substances: Narcotics (heroin, opium, Demerol or their derivatives) Hallucinogens (LSD,PCP,DMT, STP or derivatives) Stimulants (cocaine, crack, amphetamines, antidepressants) Depressants (bromides, barbituates or their derivatives) Tranquilizers (Valium, Librium, Haldol or their derivatives) Marijuana (hash, pot, grass, tea or their derivatives) (Please provide details to any “YES” answers below: Type Quantity
Frequency
2. Have you had a DUI, OUI or OWI within the last 5 years? ___ Yes ___ No. If yes, please provide the date, state of your driver’s license and your driver’s license number: 3. Have you undergone treatment for substance abuse? ____ Yes ___ No. If yes, a. Type of treatment (hospitalization, medication, b. Date of treatment, length of treatment and date treatment ended: c. Name, address and phone number of treating counselor, facility or physician: Anthem Blue Cross and Blue Shield is the trade name of In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Ohio: Community Insurance Company. In Missouri: RightCHOICE®’ Managed Care, Inc. (RIT), Healthy Alliance®’ Life Insurance Company (HALIC), and HMO Missouri, Inc. use to do business in most of Missouri. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Wisconsin: Blue Cross and Blue Shield of Wisconsin ("BCBSWi") underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") underwrites or administers the HMO policies; and Compcare and BCBSWi collectively underwrite or administer the POS policies. An independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. ALCOHOL & DRUG QUESTIONNAIRE
(CONTINUED)
4. Have you, in the past 10 years been a member of Alcoholics Anonymous, Narcotics Anonymous, or similar aftercare programs? ___ Yes ___ No. If yes, are you an active member? ___ Yes ___ No. If inactive member, when was the date last attended? Have you used any substances since your initial treatment? ___ Yes ___ No. If yes, please give details: 5. Have you had a liver function or liver enzyme test? ___ Yes ___ No. If yes, provide date/results of most All of the above statements are true, complete and correctly recorded to the best of my knowledge. I understand that the insurer will rely on these statements when determining eligibility. Signature of person treated (or parent/guardian if under 18) Anthem Blue Cross and Blue Shield is the trade name of In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Ohio: Community Insurance Company. In Missouri: RightCHOICE®’ Managed Care, Inc. (RIT), Healthy Alliance®’ Life Insurance Company (HALIC), and HMO Missouri, Inc. use to do business in most of Missouri. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Wisconsin: Blue Cross and Blue Shield of Wisconsin ("BCBSWi") underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") underwrites or administers the HMO policies; and Compcare and BCBSWi collectively underwrite or administer the POS policies. An independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

Source: http://www.cannarozziagency.com/form-library/Anthem/Individual_Health/MQ_Drug_Alcohol.pdf