CHAI Student Health Policy Sign Up

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I the undersigned (hereinafter, the "insurance applicant") ask of "Harel" Insurance Company Ltd. (hereinafter, the "Insurer") to insure me, based on all the contact of this Application.

Personal Details

Email for receiving messages, information and promotional material.

Pre-existing conditions:

For an additional premium of $350, we can provide cover for pre-existing or chronic conditions. Contact us for further details.

Parental Permission

I give permission for such diagnostic, therapeutic or emergency operative procedure as may be necessary to evaluate and treat -

HIPAA consent

I agree to waive my HIPAA (Health Insurance Portability and Accountability Act of 1996) rights, Israel’s patient privacy laws and all other applicable privacy provisions under the law, in order to allow the Harel Insurance Company medical providers , Egert and Cohen, EMA Care medical providers to communicate with myself, each other, healthcare providers, parents, and school administrators regarding my/ my childs health condition/s .This communication can be applicable via phone, email, WhatsApp, Skype, internet-based application or other forms of communication.

If student is under 18: