Health Insurance Info Form (For Health Services)
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Health Insurance Info Form (For Health Services)
The following information will be needed if lab specimens are sent to the hospital.
STUDENT INFORMATION
1.
Student's Name
*
First
MI
Last
2.
W&J ID number (This can be found on the welcome letter you received from the Admission Office after you paid your deposit to the College.)
*
3.
Student's Birth Date
*
mm/dd/yyyy
4.
Student's Home Address
*
Street
City
State
Zip Code
5.
Student's Email
*
6.
Student's Cell Phone
*
7.
Last four digits of the student's social security number
*
8.
Do you have any type of health condition or concern that W&J Health Services needs to be aware of?
*
Yes
No
If you select "yes" to the question above, our Health Services office will use this as an alert to refer them to your Report of Medical History Form. Someone from W&J Health Services may also be in contact with you for further information. Please feel free to contact Health Services with any questions or concerns at 724-223-6047 or email dhunter@washjeff.edu.
HEALTH INSURANCE INFORMATION
9.
Select which coverage you will have for the 2013-2014 Academic Year.
*
Personal Health Insurance Plan
College's Health Insurance Plan
If you selected "Personal Insurance Plan," please provide your insurance policy information below. The following information will be needed if lab specimens are sent to the hospital.
10.
Insurance Company Name
11.
Insurance Group Number/Name
12.
Insurance ID Number (Member ID or Policy)
13.
Insurance Company 800#
14.
Insurance Company's Claims Address
PARENT/GUARDIAN INFORMATION
15.
Guarantor's Name (parent/guardian)
16.
Guarantor's Birth Date
mm/dd/yyyy