Fill and Sign the Identification of Insurance for College or University and Authorization Form

Identification of Insurance for College or University and Authorization for Treatment Every student must complete this form as a new student and with any subsequent changes to the information below. This form authorizes treatment and provides important information to hospitals, clinics and attending physicians. For those participating in intercollegiate athletics, a copy of this form and a copy of the front and back of the insurance card is also required by the athletic department. Check One: [ ] New Student [ ] Returning Student [ ] Spring Semester 20____ [ ] Fall Semester 20____ Name ___________________________________ Student Identification No. __________ Date of Birth ____________ Sport(s) if applicable ________________________________ Home Street Address _______________________________ Phone No. _________________ City ____________________________________________ State __________________ Zip Code _____________________ Father or Guardian Name of Father or Guardian _____________________________________ Home Street Address _______________________________ Phone No. _________________ Address _________________________________________ City ____________________________________________ State __________________ Zip Code _____________________ Social Security Number ___________________ Medical Insurance Company or Plan _________________________________________________________ Address ________________________________________________________________ Policy Number ____________________________________ Is this Plan an [ ] HMO or [ ] PPO Is pre-authorization required to obtain treatment? [ ] Yes [ ] No Is a second opinion required before surgery? [ ] Yes [ ] No Mother Name of Mother _____________________________________ Home Street Address _______________________________ Phone No. _________________ Address _________________________________________ City ____________________________________________ State __________________ Zip Code _____________________ Social Security Number ___________________ Medical Insurance [ ] Same as Father Company or Plan _________________________________________________________ Address ________________________________________________________________ Policy Number ____________________________________ Is this Plan an [ ] HMO or [ ] PPO Is pre-authorization required to obtain treatment? [ ] Yes [ ] No Is a second opinion required before surgery? [ ] Yes [ ] No Authorization I hereby grant permission to any physician, hospital or clinic to which I am referred by the _________________________________ (Name of College or University) Health Center and/or Athletic Training Staff to treat any health problems or injuries deemed reasonably necessary for my well being. I also hereby authorize __________________________________ (Name of College or University) Health Center and/or Athletic Training Staff to treat any health problems or injuries for which I seek treatment and to release medical information necessary to process insurance claims in order to receive benefits. (For those participating in intercollegiate athletics): Your signature below authorizes the _________________________________ (Name of College or University) Health Center and/or Athletic Training Staff to discuss pertinent information related to your health or injuries. You have the right to revoke any part of this at any time by sending written notification to the Director of Health Services or the Athletic Trainer. (For all students)  The insurance policyholder needs to sign for release of insurance information .  The parent or guardian needs to sign for authorization for treatment and for release of information if student is less than 19 years of age. Required: Enclose a copy of the front and back of your insurance card. _____________________________________ (Printed Name of Student) _____________________________________ Date: _____________________ (Signature of Student) _____________________________________ (Printed Name of Parent or Guardian) _____________________________________ Date: _____________________ (Signature of Parent or Guardian) _____________________________________ (Printed Name of Policyholder) _____________________________________ Date: _____________________ (Signature of Policyholder) A copy of this document shall be considered as valid as the original. Please enclose this form in the envelope marked confidential at your earliest convenience and mail to: ____________________________________ (Name of College or University) Health Center ____________________________________________________________________________ (street address, city, state, zip code) , (Required to be on file in Health Center)