Rosario Beach Marine Laboratory Summer Health Insurance

MANDATORY HEALTH INSURANCE/WAIVER FORM
SUMMER 2014
If you have been enrolled at Walla Walla University during the current academic year, 2013-2014, you do NOT have to complete this form. Your information is on file.
As part of maintaining a healthy campus, students at the Rosario Beach Marine Laboratory are required to be covered under the mandatory Student Health Insurance Plan at a cost of $539 for the 2014 summer (coverage from June 18-September 15, 2014).  Students who have comparable health insurance such as through a parent/spouse/employer/etc. can waive out of the mandatory Student Health Insurance Plan by providing the appropriate information below.
Student's Last Name Student's First Name Current Phone Number
Permanent Street Address City Zip/Postal Code
If you are not currently enrolled as a full-time student at Walla Walla University, please select one of the choices to the left:
You will pay for insurance upon arrival at Rosario. The cost is $539.
To view the complete policy, benefits, and information please go to http://www.wallawalla.edu/life-at-wwu/student-life/campus-health-wellness/insurance/wwu-student-health-insurance-plan-2013-2014/
* Name of Insurance Company
* Policyholder's Full name
* Group Number * Policy Number Company Phone Number Company Address
* I acknowledge that I have been provided with a copy of the Notice of Privacy Practices (please check the box after viewing the Notice of Privacy Practices)
I understand that insurance plans often do not cover 100% of medical costs, and that some medical procedures are not covered at all. I understand that the balance of the cost of care not covered by my insurance plan will not be paid by Walla Walla University, and will be the responsibility of myself or my legal guardian.

Authorization/Release: My signature constitutes a release of information for any insurance company listed, health care referrals, or consultations. I recognize that if I carry private insurance, Walla Walla University is not responsible for submitting any claims that result from medical treatment. However, if I carry the school insurance policy this release allows Walla Walla University to bill the school insurance for charges incurred. This authorization shall remain valid until written notice is given to me.

I HAVE READ AND AGREE TO THE ABOVE:
* Initials:   Today's Date
  * Response required