Lindenbaum - 2024 Chai Wellcome - Student Health Insurance in Israel

First Name*
as on passport

Last Name*
as on passport

Copy of your passport*
(jpg,png image)

Date of Birth (d/m/y)*

Gender*

Marital Status*

Primary Passport Number*

Primary Passport Issuing Date (d/m/y)*

Country of Primary Passport Issue*

Please check that your passport is valid until at least three months after the end of the school year.

Secondary Passport Number (optional)

Do you have an Israeli Teudat Zehut number? *

Yes

Home Address

Street & Number*

City*

ZIP*

State*

Country*

Contact Details

Email* Email for receiving messages and information

Parents Email*

Phone No. in Israel/home

Cellphone in Israel/home*

Program Address- Your Details in Israel

Name of Yeshiva/Sem/Program*

City

Have you previously had health insurance in Israel? *

Yes

It is the responsibility of the policy holder to inform us if there are any changes to the end date of his/her policy.

Program Start Coverage in Israel (d/m/y)*

Program End Coverage in Israel (d/m/y)*

For any changes, please contact rochel@egertcohen.co.il

Health Declaration

1. Height (in cm)*
Convert from inch

2. weight (in kg)*
Convert from lbs

3. Waist circumference (in cm)*
Convert from inch

4. Are you a smoker? If yes, for how many years? How many cigarettes per day?

Yes

5. Have you have smoked in the past? If so, please detail: When did you quit? How many years did you smoke for? How many cigarettes per day?

Yes

6. Are you limited partially or fully in performing independently one or more of the following activities: walking, standing up, sitting down, getting dressed, washing yourself, eating, drinking, controlling your bowels.

Yes

7. Are you suffering or have you suffered from any disease in the past year? Mention which illnesses and when.

Yes

8. Are you taking or have you taken any medication on a regular basis? List all medications and reason for medication and provide current doctors letter below.

Yes

9. Have you been admitted to a hospital or other medical institution? Mention date, the reason for admission, and the treatment you received.

Yes

10. Have you undergone surgery? What date, and what type of surgery?

Yes

11. Are you a candidate for medical treatment that includes surgery or hospitalization?

Yes

12. Do you consume alcohol/drugs? If yes, please provide details. If you drink socially and responsibly, please indicate "social drinker."

Yes

13. Have you undergone any special examinations in the last 5 years (MRI, CT, bone scan, mammography)?

Yes

14. Have you undergone any lab and/or medical examination in the last year? Provide the reason, date, and result, including abnormal results.

Yes

15. Do you suffer from any chronic disease (active or dormant)? If yes please specify and provide current doctors letter below

Yes

16. Have you been diagnosed with any autoimmune disease, particularly lupus? If yes please specify and provide current doctors letter below

Yes

17. Do you suffer or have you suffered from any infectious disease? If yes please specify and provide current doctors letter below

Yes

18. In the last six months, have you lost 6kg or more in weight?

Yes

19. Do you suffer from tiredness or chronic fatigue?

Yes

20. Do you suffer from a chronic cough?

Yes

21. Do you know of any medical problem (incl. birth defects) that affects you and is not mentioned in this declaration? Please specify and provide current doctors letter below

Yes

22. Have you received special home care services? If so, what and when?

Yes

23. Have you been in a car/work/other accident?

Yes

24. Are you or have you been under medical / developmental / psychological / psychiatric supervision?

Yes

Are you suffering or have you suffered from one or more of the following diseases?

25. Diseases of the brain and nervous system, paralysis, fainting, epilepsy, movement disorders, psychiatric disorders (TIA, CVA, dementia, Alzheimer’s, emotional exhaustion).

Yes

26. Illnesses of the respiratory system, asthma, tuberculosis, chronic lung infection, hemoptysis, COPD, pneumothorax.

Yes

27. Cardiovascular diseases of any kind, high blood pressure.

Yes

28. Diseases of the digestive system, liver, gall bladder, hernia, hemorrhoids

Yes

29. Kidney diseases, urinary tract diseases, dialysis.

Yes

30. Bone and joint diseases, neck and back pain.

Yes

31. Metabolic diseases, diabetes, thyroid disorder, hyperlipidemia, blood and clotting diseases, anemia.

Yes

32. Cancer. If yes, when?

Yes

33. Skin and sexually transmitted diseases – syphilis, AIDS, persistent sores, herpes of all types, skin growths of all types.

Yes

34. Are you a carrier of or have you been diagnosed with HIV and/or hepatitis?

Yes

35. Eye diseases, ear diseases, hearing/vision impairment, throat diseases, nose diseases, plastic surgery.

Yes

36. Amputations/limb weakness or paralysis.

Yes

37. Degenerative diseases of the nervous or muscular systems (Parkinson’s, polio, MS, ALS).

Yes

38. Have you suffered or are you currently suffering from irregular periods, cysts, hemorrhages, breast diseases (including lumps), cervical diseases, or ovarian diseases? Have you undergone an examination to discover cancerous growths and/or a mammography?

Yes

39. Are you pregnant? Pregnant women must attach a letter from their gynecologist, including details on the progression of the pregnancy.

Yes

40. Have you undergone or are you undergoing or do you require fertility treatments?

Yes

41. Any other medical issue?

Yes

If you answered yes to questions 8,15,16,17,21 or 39 above, please provide a current letter from your physician indicating diagnosis, treatment, prescription for any medication and other relevant information. (PDF ONLY)

Optional: Personal Effects coverage (clothing, electronics, jewelry, etc.) covered for theft, fire/water damage in the dorm for up to $4500. It also includes All Risks cover outside the dorm, for electronics or jewelry up to $900. There is no coverage for cell phones, glasses, cash or any items left in a car or bus. In the event of a claim there is a deductible of $35.
The cost of a personal effects policy is $50. For questions regarding personal coverage contact: ahuva@egertcohen.co.il

Yes

The following charge will be paid for directly by the participant.

If the student has any of the following medical conditions, pre-existing coverage is REQUIRED:

Anxiety/depression
ADHD/ADD
Allergies-Epipen
Mental health conditions
Epilepsy
Diabetes (without insulin)
Thyroid disorders
BMI (over 30)
High cholesterol/Blood Lipids
ACNE/Skin conditions
Asthma
Anemia

There are some other conditions that Maccabi might consider to be pre-existing. In certain cases, Maccabi may request recent bloodwork. In such a case, we will be in touch with you.

Please cover for pre-existing conditions
Cost: $75

Yes

The following charge will be paid for directly by the participant.

I, the undersigned, herby confirm that I have read and understood the information given on the restrictions of the WELL-COME program which exclude coverage for birth and fertility:
5.3 The following services are not included in the program:
5.3.4 Any treatment or examination that are related to birth, including birth expenses, treatment of a new born (including birth of a premature baby), hospitalization for complications of pregnancy, birth, abortion, curettage etc.
5.3.5. Fertility Treatments

I agree *

Full Name

Release of Confidentiality
I agree to waive my HIPAA (Health Insurance Portability and Accountability Act of 1996) rights, Israel’s patient privacy laws (Protection of Privacy Act 1981 and the Patient’s Rights Law 1996) and all other applicable privacy provisions under the law, in order to allow the Staff of Chai Travel Assistance Services (CTAS) and/or the staff of my program to communicate with myself, each other, healthcare/therapeutic providers, parents, and school administrators regarding my health condition/s. This communication can be applicable via phone, email, WhatsApp, Skype, internet-based application or other forms of communication.

I hereby declare, consent and agree that:
* All statements are correct, complete, and provided voluntarily.
* I have read the terms and conditions of the plan as displayed on the Maccabi website, and I accept all the terms and conditions stated therein.
* I, the undersigned, confirm that I have read and understood the plan’s terms and conditions and that all the terms above have been explained to me.
* I acknowledge that Maccabi has the authority to either approve or reject my application for membership of the plan, with no obligation to justify its decision.
* I acknowledge that the contract will be in effect only after I have received confirmation from Maccabi of my acceptance to the plan and after the initial membership fees have been paid in full.
* I acknowledge that Maccabi will be exempt from providing care related to a congenital defect/disease, including hereditary diseases and/or my state of health and/or medical event and/or
disease, whether treated or not, and/or their results, directly or indirectly, which were caused and/or exacerbated due to a state of health which existed prior to the start date of the membership.
* I acknowledge that the monthly rate is updated periodically according to the terms and conditions of the plan.
* I acknowledge that Maccabi has the authority to determine a supplementary fee to the fixed rate or exclude a medical condition, pursuant to the medical state determined as a condition of the
membership’s approval.
* I acknowledge that the application and health declaration are valid for a month from the day they are signed.
* The purpose of staying in my country is not to receive medical treatment and I do not know of any medical treatment I need. All the details I gave in my health statement are true and complete.
If the information I provide is incorrect or incomplete, Maccabi may terminate my membership in the program at any time.
Supplementary Insurance
* I acknowledge that the Well-Come plan membership fees do not include payment for supplementary insurance or Nursing Gold or Keren Maccabi, and these will be paid in addition.
* I acknowledge and I agree herein that my membership in Maccabi Zahav and/or Maccabi Sheli is subject to the joining terms that apply to a member of the Well-Come plan.

Signature/Full name of Parent/Guardian

Signature/Full name of Student *

CTAS

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Lindenbaum - 2024 CHAI 'Wellcome' Student Health Policy Sign Up

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