Health Questionnaire



Dear Member Dentist,

We are moving forward in our Health Insurance plan feasibility study. These are the perks for you to consider when contemplating participation:

  • Getting a good benefits package will help attract and retain good talent.
  • In a group plan you pay with pretax dollars (you get a tax benefit). In an individual plan, you do not get a tax benefit. Some employees may consider reducing pay to get health insurance benefits for this reason.
  • With current income, you do not likely qualify for the Obamacare subsidies in the individual plan you may currently be on.
  • Obamacare options are declining with President Trump uncertainties.

The next step in assessing what the Co-Op can do to offer its members a quality and cost competitive Health Care plan requires specific information about you and any other full-time employee in your practice. The questionnaire which follows has been prepared for that purpose and will need to be completed for yourself and employees in your office. If an employee does not want coverage they will need to fill out the portion of the questionnaire that states they do not want coverage. The information submitted on these questionnaires will be used to formulate the benefits and cost (premiums) of such a plan.

Please note, the submission of these questionnaires DOES NOT constitute an application for coverage and does not obligate anyone completing a questionnaire to apply or pay for anything!

If, as a result of this study, a Group Medical Plan can be and is offered by the Co-Op, you will then be informed about all aspects of the plan and may choose to then authorize the use of these questionnaires as applications for your coverage under the plan.

Next Steps: Please choose someone in the office to act as the “Office Insurance Administer (OIA).” The OIA will fill out the form below. An e-mail will then be sent explaining next steps. Time is of the essence! Please make every effort to have the questionnaires completed ASAP. The sooner we get a good number the sooner we can get more details on potential Health Insurance Plans.

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