Student Health Insurance Election Form

All students are required to have medical insurance that covers them in North Carolina and in the USA.

STUDENTS WILL NOT BE ALLOWED TO ATTEND CLASS WITHOUT NC INSURANCE COVERAGE

This form must be completed and signed no later than August 10, 2018.

The American Hebrew Academy requires all enrolled boarding students to be covered by a U.S. based health insurance company that provides basic and catastrophic medical insurance protection. Please initial the appropriate box below.

U.S. RESIDENT FAMILIES

My child has basic and catastrophic health insurance coverage issued by an insurance provider authorized to provide coverage in NORTH CAROLINA and throughout the United States. I understand that the Academy makes no representation as to applicable insurance coverage while my child is a student at the Academy. I am attaching proof of my child’s insurance coverage or will provide proof of coverage by August 10, 2018.

I wish to purchase basic and catastrophic health insurance offered for my child through the Academy at a cost to me of approximately $1,300 for the period August 15, 2018 – June 15, 2019. I understand the information delineating the coverage and I elect to purchase this insurance. The following link will be available later in the summer and will state the exact charge and coverage for this insurance: http://www.collegiaterisk.com/schools/aha.aspx I authorize the Academy to purchase this coverage on my behalf and charge my account accordingly. Please note that this coverage does not include medication costs and some other specific medical situations.

INTERNATIONAL FAMILIES

My child has basic and catastrophic health insurance coverage issued by an insurance provider authorized to provide coverage in the United States. I understand that the Academy makes no representation as to applicable insurance coverage while my child is a student at the Academy. I am attaching proof of my child’s insurance coverage or will provide proof of coverage by August 10, 2018. The insurance must have a USA telephone number and USA address and must be in English.

I wish to purchase basic and catastrophic health insurance offered for my child through the Academy at a cost to me of approximately $1,300 for the period August 15, 2018 – June 15, 2019. I have read the information r delineating the coverage I elect to purchase. The following link will be available later in the summer and will explain the exact charge and coverage: http://www.collegiaterisk.com/schools/aha.aspx. I authorize the Academy to purchase this coverage on my behalf and charge my account accordingly. Please note that this coverage does not include medication costs and some other specific medical situations.

FOR ALL:

I understand that I am personally responsible to pay all deductibles, co-pays and health care related fees and expenses incurred by the Academy on behalf of my child that may not otherwise be paid by my child’s health insurance provider including costs for all medications. My credit card may be used for these expenses as well as for other medical charges that are not paid by my insurance provider in a timely manner. All statements and receipts will be sent to me as soon as they are available.

Student Name *

Graduation Year *

Parent Name *

Date * +

Parent Signature *

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