Student-Athlete Health Insurance Questionaire

Does your plan require a referral from a primary physician?   Yes   or   No

If yes, please list the physician's name and phone number:  ___________________________________________________

Comments: ___________________________________________________________________________________________

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Have you purchased the student health insurance plan from the Siena College Health Service?   Yes   or   No

If yes, please list the policy information:  ___________________________________________________________________

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If your son or daughter has medical insurance from a previous marriage as mandated in a divorce decree, please list the

details for filing a claim: _________________________________________________________________________________

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If your son or daughter has medical insurance from government service or armed forces please list the details for filing a

claim: _______________________________________________________________________________________________

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Please list any details as to the coverage or restrictions of your insurance plan (especially if you are covered by an HMO):

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I/We agree that all the information provided in this document is accurate and complete to the best of my/our knowledge. I/We
understand that any incorrect or undisclosed information can result in duplicate payments, creating a substantial overpayment.
The responsibility of such payment will be the obligation of the undersigned to reimburse in full, upon request, all amounts
deemed refundable.

Parent/Guardian/Father: ___________________________________________________   Date: _______________________

Parent/Guardian/Mother: ___________________________________________________   Date: _______________________

Go to, Under 18 form.