Midreshet Lev 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

No

Email* Email for receiving messages and information

Parents Email*

Cellphone in Israel/home*

Phone No. in Israel/home

Name of Yeshiva/Sem/Program*

Street & Number *

City *

Have you previously had health insurance in Israel? *

Yes

No

Name of Israeli Insurance Company & Plan*

Period of Insurance

Reason for Ceasing Insurace

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 chaimedical1@gmail.com

Please pay attention to your measurements when you are converting to centimeters and kilogram

1. Height (in cm)*
Convert from inch

cm

2. weight (in kg)*
Convert from lbs

kg

3. Do you smoke? If yes, how long (in years) have you been smoking? How many cigarettes a day? *

Yes No

4. Are you sick now, or have you been ill over the last year? Please detail the illness and its time of occurrence. *

Yes No

5. Are you fully or partially prevented from carrying out one or more of the following activities independently: sitting, standing , walking, showering, dressing, eating, drinking, or bowel continence? *

Yes No

6. Have you ever been hospitalized at a hospital or any other medical institution? Please state the date, reason for hospitalization and the treatment you received. *

Yes No

7. Have you undergone lab tests and/or any medical tests over the last year? Please detail cause, time and results *

Yes No

8. Have you undergone surgery? Please describe the time and nature of surgery *

Yes No

9. Have you taken, or are you currently taking medication regularly? Please provide details *

Yes No

10. Have you undergone any special tests over the last 6 years such as MRI, CT, bone scintigraphy or mammography? Please detail when and why. *

Yes No

11. Do you consume drugs or alcohol? *

Yes No

12. Have you received special services for treatment at home? *

Yes No

13. Have you been injured by a work/ car/ other accident? *

Yes No

14. Do you receive a disability/ nursing stipend from any entity whatsoever? *

Yes No

15. Have you been under medical/ developmental/ psychological/ psychiatric follow-up? *

Yes No

16. Are you suffering or have you suffered in the past from a birth defect/ genetic (hereditary) disease or temporary/ permanent disability? *

Yes No

17. Do you suffer from any active or dormant chronic disease whatsoever? *

Yes No

18. Are you suffering from or have you suffered in the past from any infectious disease whatsoever? *

Yes No

19. Have you lost 6 or more kg over the last six months? *

Yes No

20. Are you suffering from exhaustion or chronic exhaustion? *

Yes No

21. Metabolic/ hormonal (endocrinological) illnesses including diabetes, hyperlipidemia, gout, Gaucher's disease, FMF, thyroid gland, parathyroid gland, pituitary gland (prolactinoma/ prolactinemia), growth disorders *

Yes No

22. Nervous system, brain and/ or developmental disabilities including epilepsy, cerebrovascular accident (CVA), brain tumor, multiple sclerosis, muscular dystrophy, tremor, Parkinson's disease, paralysis, polio, Asperger syndrome, autism, attention deficitdisorder, dizziness and fainting *

Yes No

23. Mental illnesses, including depression, anxieties, post-traumatic stress disorder. Have you been diagnosed with a mental illness? *

Yes No

24. Malignant diseases, tumors including: benign tumor, cancerous tumor, and pre-cancerous tumor *

Yes No

25. Lung and respiratory tracts: including; asthma, bronchitis, COPD (Obstructive pulmonary disease), emphysema, sarcoidosis, sleep apnea, cystic fibrosis, pneumonia, tuberculosis *

Yes No

26. Visual system including: visual disability above number 7, retinal detachment, glaucoma (intraocular pressure), cataract, uveitis, keratoconus, and blindness *

Yes No

27. Ear-nose-throat system including: hearing loss, Meniere's disease, tinnitus, polyps, vocal chord damage *

Yes No

28. Cardiovascular/ blood pressure/ blood vessel system including: high blood pressure, heart attack, heart failure, congenital heart defect, heart arrhythmia, valve damage, thrombosis, pulmonary embolism, abdominal aortic aneurysm, enlarged veins, pulmonary hypertension, atherosclerosis *

Yes No

29. Hernia and digestive system including: hernia of any type, reflux, Crohn's disease, colitis, ulcerative colitis, rectal hemorrhage, rectocele, hepatitis/ jaundice, enlarged liver, fatty liver disease, cirrhosis, gallbladder stones, infection in the pancreas (pancre-atitis) *

Yes No

30. Kidneys and urinary tract including: renal failure, polycystic kidney, kidney or other defect, stones, urinary tract reflux, bladder hernia, blood/ protein in the urine, benign hypertrophy prostate, other problems in the prostate *

Yes No

31. The blood system, immune system, infectious diseases including: anemia, irregular blood count, disruption to blood coagulalion, thalassemia major/ intermedia, hemophilia, enlarged spleen, immune system disorders, AIDS/ carrier, continuous fever lasting more than 3 months *

Yes No

32. Musculoskeletal system and joints including: joint diseases, hernia, dislocation, tendon/ ligament damage, disc herniation, osteoporosis, degenerative joint disease, rheumatoid arthritis, lupus, chronic fatigue syndrome *

Yes No

33. Skin and venereal system including: psoriasis, pemphigus, eczema, skin lesion and/or tumor, infectious skin disease, papilla- ma/condyloma *

Yes No

34. Reproductive system: Men- breast tissue lump/abscess, fertility disorders, testicular tumor, varicocele, hydrocele, hypospadias. Women - breast tissue lump/abscess, irregular bleeding outside of the monthly period, uterine fibroids, ovarian cyst, recur- ring miscarriage, uterine prolapse and/ or vaginal wall prolapse, fertility problems, endometriosis *

Yes No

35. Women - are you pregnant? If yes, please attach a letter from a gynecologist including documentation and pregnancy monitaring. *

Yes No

36. Do you have a medical condition that is not mentioned in these paragraphs and requires medical investigation? *

Yes No

If you answered yes to any of the questions above 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

No

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 Meuchedet might consider to be pre-existing. In such a case, we will be in touch with you.

Please cover for pre-existing conditions
Cost: $75

Yes

Signature/Full name of Parent/Guardian

Signature/Full name of Student *

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