HEALTH INSURANCE INFORMATION FORM
Participant Name_________________________________________ Date of Birth ___/___/___
Participant Address _____________________________________________________________
(Street) (City) (State) (Zip)
Home Phone Number_____________________ Cell Phone Number______________________
Medical Insurance Company Name___________________________Effective Date___/___/___
Insurance Company Address_______________________________________________________
(Street) (City) (State) (Zip)
Insurance Company Phone Number_____________________ Group #_____________________
Policy #____________________________Policyholder’s Name__________________________
Relationship To Participant______________ Policyholder’s Phone________________________
Policyholder’s Address ___________________________________________________________
(Street) (City) (State) (Zip)
Participant (and the parent(s) or legal guardian(s), of participant, if applicable) hereby authorize the release of any medical information, which might be needed in connection with payment for medical services.
Participant (and the parent(s) or legal guardian(s), of participant, if applicable) request that payment under my medical insurance program be made directly to the provider on any bill for services rendered by that provider. I understand that I am financial responsible for all costs not paid by my medical insurance program.
Signature of Parent/Guardian__________________________________Date___/___/___
Signature of Parent/Guardian__________________________________Date___/___/___
EMERGENCY INFORMATION AND CONTACTS
Name of Personal Physician________________________________Phone__________________
Physician Address_______________________________________________________________
(Street) (City) (State) (Zip)
Emergency Contact Person(s) in case of Emergency:
Name______________________________Relationship_________________________________
Address_______________________________________________________________________
Daytime Phone______________Evening Phone_____________Cell Phone__________________
Name______________________________Relationship_________________________________
Address_______________________________________________________________________
Daytime Phone______________Evening Phone_____________Cell Phone__________________
Participant (and the parent(s) or legal guardian(s), of participant, if applicable) hereby further consent to KIIH Inc. staff to obtain whatever medical treatment and/or care is deemed necessary by such staff for the health and well-being of the participant during the term of program participation, including the consent to obtain and have administered any emergency medical or surgical treatment recommended by a physician licensed to practice medicine in the state of Michigan.
In rare instances, a medical or surgical emergency requiring treatment arises in which written consent by parent(s) or guardian(s) is legally required, and the proper person cannot be located. In this event, and in order to avoid delay that might jeopardize the life or recovery of a participant, we request the following permission from parent(s) or guardian(s), with the understanding that every effort will be made to contact you in an emergency.
I hereby grant permission to authorize any member of KIIH, Inc. or other physicians or surgeons, to give emergency anesthesia and perform medical or surgical procedure(s) on my son / daughter__________________ in the event that he/she is unable to contact me when further delay might jeopardize the life or impair recovery.
Signature of Parent/Guardian__________________________________Date___/___/___
Signature of Parent/Guardian__________________________________Date___/___/___
HEALTH HISTORY
Please list any allergies or other pertinent medial conditions:
_______________________________________________________________________
_______________________________________________________________________
Please list any medications currently taken and there directions:
_______________________________________________________________________
_______________________________________________________________________