Lev HaTorah 10 Month CHAI 'Wellcome' Student Health Policy Sign Up

To signup for this insurance policy, please proceed as follows:

  1. Download this PDF form

    The form does not have to be printed, and can be filled out on your computer.
  2. When you're done, don't forget to save it, and return to this page
  3. Proceed below to fill out the personal details and upload the form you have just filled out.

Please note when filling out the form:

  1. If you are taking medication, please state the reason (question 8)
  2. If you have been hospitalized/had surgery-please give dates and details (questions 9, 10)
  3. Alcohol- if yes, state social drinking (unless other) question 12
  4. Chronic conditions-pls provide current doctor’s letter (questions 15, 16, 17)
  5. Please add an extra page if you need to add information.
  6. Date of birth - you MUST give the Israeli date format: DD/MM/YYYY.
  7. You MUST give your weight, height and waist circumference in kilograms and centimeters.

 

It is the responsibility of the policy holder to inform us if there are any changes to the end date of his/her policy.
Email for receiving messages and information


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.