DIYBSfor Employees

Health QuestionnaireInstructions

Introducing DIYBS for Employees

In effort to obtain the most affordable health coverage, your employers has elected to consider self-funded health plan options through DIYBS. Offering a self-funded health plan requires that all employees considering coverage complete a Health Questionnaire. Enclosed you will find detailed instructions to completing the needed Health Questionnaire.

Information provided in this Health Questionnaire is confidential and is not shared with your employer, their representing agents and/or brokers. Additionally, any misstatements and/or omissions made on this questionnaire may cause you and/or your covered dependents to lose coverage and/or experience denied claims by the Health Plan or the Stop Loss provider.

Any statements and answers on this questionnaire and any subsequent information you provide are the basis for coverage under your Health Plan and the Stop Loss Policy. The statements and answers to the questions must be true and complete to the best of your knowledge.

Any person who knowingly and with intent to defraud or deceive any insurance company, submits an insurance application or statement of claim containing any false, incomplete or misleading information may be subject to civil or criminal penalties.

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TABLE OF CONTENTS

DIYBS Registration ……………………………………………………….. 2

Personal Information …………………………………………………... 8

Adding Dependents ……………………………………………………… 9

Previous Coverage ……………………………………………………….. 10

DIYBS Health Questionnaire …………………………………………. 11

Submission …………………………………………………………………….. 13

Steps 1: Visit DIYBS Secure Portal

Your employer will provide you with the URL and Employer Passcode

Step 2: Register/Log InYou must set up a DIYBS profile to confirm you are an eligible employee.

Select Sign Up Now

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Steps 3: REGISTER EMAILInput your Email and Verify

Steps 4: RETRIEVE VERIFICATION CODELog into the provided email and retrieve the Verification Code from the email you have received from Microsoft (on behalf of DIYBS)

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Steps 5: VERIFY EMAILInput provided Verification Code from the Microsoft email and select “Verify Code”.

If you did not receive code you may select to Send New Code.

Steps 6: CREATE PASSWORDUpon Verification you will be prompted to add a Username and Password → Create.

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Steps 7: RECORD LOOKUPThe required information to locate your Employee record and enter the Employer Code provide by your Employer → Proceed

If you did not receive your Employers Code, contact your HR/Benefits Contact.

You may exit this process by logging out and return to continue working on your Health Questionnaire at anytime.

IMPORTANT: Any person who knowingly and with intent to defraud or deceive any insurance company, submits an insurance application or statement of claim containing any false, incomplete or misleading information may be subject to civil or criminal penalties.

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Steps 8: PERSONAL INFORMATIONComplete all applicable and required sections of your Personal Information → Identification → Contact → Home Address →Mailing Address → Activity at Work

IMPORTANT: Any person who knowingly and with intent to defraud or deceive any insurance company, submits an insurance application or statement of claim containing any false, incomplete or misleading information may be subject to civil or criminal penalties.

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Step 9: DEPENDENTSInput Dependents you plan to cover on your health plan by selecting Add Member

Input all the required data for the Dependent you wish to cover on your health plan.

REPEAT Step 9 for every Dependent you wish to enroll on your health plan.

IMPORTANT: Any person who knowingly and with intent to defraud or deceive any insurance company, submits an insurance application or statement of claim containing any false, incomplete or misleading information may be subject to civil or criminal penalties..

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Steps 10: PREVIOUS HEALTHCARE COVERAGEInput Verification of Prior Health Coverage for your and/or your Dependents → Next

IMPORTANT: Any person who knowingly and with intent to defraud or deceive any insurance company, submits an insurance application or statement of claim containing any false, incomplete or misleading information may be subject to civil or criminal penalties.

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Step 11: HEALTH QUESTIONNAIREComplete ALL questions of the Health Questionnaire (A thru U) for your ANDyour covered Dependents as it relates to the Past 5 Years→ Next

IMPORTANT: Any person who knowingly and with intent to defraud or deceive any insurance company, submits an insurance application or statement of claim containing any false, incomplete or misleading information may be subject to civil or criminal penalties.

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Step 12: HEALTH QUESTIONNAIRE CONDITIONSFor every Health Question in which the response was YES, select input the affected member and provide the condition details, including ALL medications.

IMPORTANT: Any person who knowingly and with intent to defraud or deceive any insurance company, submits an insurance application or statement of claim containing any false, incomplete or misleading information may be subject to civil or criminal penalties.

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Step 13: TERMS & CONDITIONSRead & Accept Terms and Conditions → Submit and Print.

IMPORTANT: Any person who knowingly and with intent to defraud or deceive any insurance company, submits an insurance application or statement of claim containing any false, incomplete or misleading information may be subject to civil or criminal penalties.

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COMPLETE → You will receive and email confirming submission of your Health Questionnaire along with a copy for your records.

Any questions or inquiries regarding the Health Questionnaire process should be directed to your Employer.

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