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As part of maintaining a healthy campus, Walla Walla University (WWU) requires Rosario students be covered under the MANDATORY Student Health and Additional Accident Insurance. This requirement will be waived if the student submits documentation of insurance that will cover medical expenses. Not all insurances, especially HMOs, cover outside of your home area.
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Student's Last Name
Student's First Name
Current Phone Number
Permanent Street Address
City
Zip/Postal Code
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If you are not currently enrolled at Walla Walla University, please select one of the choices to the left: |
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Name of Insurance Company
Company Phone Number
Company Address
Group Number
Policy Number
Policyholder's Full name
Policyholder's Birth Date
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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:
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Initials:
Today's Date
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WALLA WALLA UNIVERSITY
| 204 SOUTH COLLEGE AVENUE, COLLEGE PLACE, WA 99324
| (800) 541-8900 | (509) 527-2253 FAX
