Application For Viva Health Mandatory Student Health Plan Form
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1Please mail to: Student Health Service
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Birmingham, AL 35294-2042
APPLICATION FOR VIVA HEALTH
MANDATORY STUDENT HEALTH PLAN
(Do not complete this form if you desire Optional/Undergraduate Student Insurance or if you are signing a waiver.
This is to be completed only if you are enrolled in one of the schools listed below that mandates health insurance.)
DATE: ______/________/________
Blazer ID:
Social Security #:
Telephone #:
E-mail Address:
Student’s Last (Family) Name:
Student’s First Name:
Middle Initial:
Birth Date:
/ /
Sex: o Male o Female
Street Address:
City:
State:
Zip Code:
Semester:
o Fall Semester o Spring Semester o Summer Semester
o Other __________________
School or College in which you are enrolling (Check one):
o Medical
o Dental
o Optometry
o Nursing
o Health Related Professions
o Public Health
o Graduate (Degree Seeking) o International Student o International Scholar
Coverage Desired: o Student Only o Student & Spouse o Student, Spouse & Child(ren)
Please be sure to choose a Personal Care Provider for any spouse or children added to the plan.
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o Female
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I desire coverage by V
H
Student Health Plan to become effective when I am officially enrolled. I understand that my insurance premium will
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ealtH
be billed to my Student Account in two payments. I understand that it will be Automatically Renewed at the beginning of the next UAB academic
year if I remain eligible. I will be responsible for payment of premiums. I will notify Student Health Services when I am no longer a student. I (we)
authorize the release and use of all my (our) medical records or information necessary to process claims or in any way determine benefits due. Medical
information can also be used to execute the obligations imposed on V
H
, Inc. by state or federal statutes, as well as for the Quality Assurance
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or Peer Review programs conducted by V
H
, Inc. or its designated agents.
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STUDENT SIGNATURE: _______________________________________________
DATE: ________________________
For Office Use Only
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ATE
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EFFECTivE DATE: ___________________
mEmBER numBER: ___________________
Lgdoc1 (2007)
VH1001104
1013000 Viva.indd 1
6/4/07 10:31:28 AM
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