Insurance Form
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NSURANCE
NFORMATION
YES
Student is enrolled in the Lafayette College Student Health Insurance underwritten by University Health Plans.
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NO
If the answer to the above question is yes, you need not complete the information in the boxes. Move directly to the bottom of the form,
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provide copies of your insurance card and sign below.
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YES
Student is covered under another health insurance plan that I have verified to be equivalent to the University Health Plan.
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ALL
NO
If the answer to the above question is yes, please complete
sections below.
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S
& S
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UBSCRIBER
TUDENT
NFORMATION
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Student’s Name : _________________________________________ Campus Box No. : __________Date of Birth : ____/____/_____
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L# or Social Security Number :__________________________________ Cell Number : (
) __________-___________
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Subscriber’s Name : _____________________________________________________________Date of Birth : ____/____/_____
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Address : __________________________________________ City : _____________________ State : _____Zip : _____________
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circle one
Relationship to student :
Self
Parent
Guardian
Other ____________________________
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Subscriber’s Employer : _____________________________________________________________________________________
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NSURANCE
NFORMATION
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Name of Insurance Company : _______________________________________________________________________________
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Insurance Company Billing Address : __________________________________________________________________________
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City : ________________________________
State : ________
Zip: _______________
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Telephone Number : (
) ___________________________________
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Insurance ID number : _________________________________
Group number : ___________________________________
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Does your insurance cover out of area non-emergent care?
YES
NO
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Does your insurance require a guest provider?
YES
NO
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Do you need a referral from your primary care physician for outpatient services? YES
NO
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Please CIRCLE those services that require a referral or authorization to obtain insurance coverage :
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CT Scan
MRI
Bone Scan
Ultrasound
Xray
Other __________________________________
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Please circle the Lab in your network?
Quest
LabCorp
Health Network
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Please place copies of the front and back of your insurance card below.
FRONT OF INSURANCE CARD
BACK OF INSURANCE CARD
By signing below, I give permission to be treated at the Student Health Center and for Bailey Health Center to release information
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necessary to process insurance claims
Student Signature____________________________________________________
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