Odyssey Health Form - Plattsburgh State University Of New York printable pdf download

Odyssey Health Form - Plattsburgh State University Of New York

Odyssey Health Form

Plattsburgh State University of New York

Student Information (to be completed by the student)

Name: ___________________________________

Date of Birth: _______________

Shirt Size: _____________________

How did you learn about the Odyssey Program? ___________________________________

Do you have any Dietary Restrictions? ___________________________________________

Person to Notify In Case of an Emergency (to be completed by the student)

Name: _________________________________________________

Relationship to You: Parent / Legal Guardian (circle one)

Home Address: ____________________________________________________________

Home Phone Number: (______) ______-_________

Cell Phone Number: (______) ______-_________

Health Insurance (to be completed by the student)

SUNY Plattsburgh requires that all full-time students enroll in the Student Accident and Sickness Insurance

Plan or be covered by comparable and adequate insurance through another source (i.e. parent’s or spouse’s

health insurance). Students that are covered by managed care plans outside of Plattsburgh are recommended

to investigate the out-of-network benefits of the plan. If these out-of-network benefits significantly restrict

the use of health care services in Plattsburgh, we recommend that the student also purchase Student

Accident and Sickness Insurance in addition to the managed care plan. Students have the opportunity to

accept or decline Student Accident and Sickness Insurance when they receive a bill for each semester.

Please indicate whether you are covered by comparable insurance, will enroll in Student Accident and

Sickness Insurance, or will have coverage from both by checking the appropriate box below:

I will enroll in the Student Accident and Sickness Insurance Plan*.

I am covered by comparable insurance (please attach a photocopy of your insurance card).

I will enroll in the Student Accident and Sickness Insurance Plan* and am covered by comparable

insurance.

*Information can be found online at Questions are referred to (800) 444-5530.

Student Name:________________________________ Date of Birth: _______/_______/________

1. Have you ever been or are you now being treated for any of the following (check appropriate box)?

Abnormal PAP smear

Diabetes

Infectious mononucleosis

ADD/ADHD

Disorders of eye/ear/nose/throat

Inflammatory bowel disease

Alcohol/substance abuse

Depression/anxiety

Injury to legs/feet/arms/hands

Odyssey Health Form - Plattsburgh State University Of New York