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What is a Jersey Health Declaration Form and how can it help you? A health declaration form is a legal document that outlines your medical conditions. It will list the diagnosis and procedures followed in treating your particular condition, as well as the extent of damage or loss suffered from your condition. In general, it will list your name, address, city, phone number, insurance company, birth date, social security number, physician's name, and whether you are a United States citizen or not.