‫סטודנטים יקרים‪,‬‬ ‫סטודנטים הנרשמים ללימודים או לכל פעילות אקדמית אחרת באוניברסיטה העברית‪,‬‬ ‫שאינם אזרחי מדינת ישראל‪ ,‬מכוסים בביטוח בריאות על ידי האוניברסיטה העברית‬ ‫(רצ"ב עיקרי הכיסוי הרפואי)‪.‬‬ ‫לידיעתכם‪ ,‬שכר הלימוד יכלול את עלות הביטוח‪ .‬כל סטודנט יחויב בהתאם לתקופת‬ ‫הלימודים אליה הוא נרשם (שנתית או סמסטריאלית)‪.‬‬ ‫חשבונות סטודנטים‬ ‫האגף‬ ‫למינהל תלמידים‬ ‫‪Account Section‬‬ ‫‪Students Administration‬‬ ‫‪Department‬‬ ‫להלן הנחיות ההרשמה לביטוח‪:‬‬ ‫‪ .1‬הנך מתבקש‪/‬ת למלא את טופס ההרשמה הכולל בתוכו את הצהרת הבריאות‪ ,‬לחתום‬ ‫ולהעביר את הטפסים בדחיפות (לא יאוחר מ‪ 14-‬יום מיום ההרשמה) למדור חשבונות‬ ‫סטודנטים באחת מהדרכים הבאות‪:‬‬ ‫א‪ .‬באמצעות פקס‪+972-2-5881143 :‬‬ ‫ב‪ .‬צרפו את הטופס הסרוק לפנייה ושלחו‪ ,‬דרך אתר האוניברסיטה העברית‬ ‫באינטרנט‪.http://pnyot.huji.ac.il/mador_scl :‬‬ ‫‪ .2‬סטודנט אשר חולה באחת המחלות המוחרגות‪ ,‬חייב להציג מסמכים רפואיים‬ ‫ולהעבירם לחיתום רפואי באופן פרטני‪ ,‬לפי פרוטוקול החיתום והתנאים המיוחדים‬ ‫בחברת הביטוח‪.‬‬ ‫‪ .3‬במידה ויש בידך ביטוח רפואי מארץ מוצאך‪ ,‬הנך מתבקש להציגו במדור לחשבונות‬ ‫סטודנטים ולחתום על הצהרה המשחררת את האוניברסיטה מאחריות רפואית עבורך‪.‬‬ ‫רק לאחר הצגת הביטוח מארץ מוצאך וחתימתך על ההצהרה‪ ,‬תוחזר לך הפרמיה שנגבתה‬ ‫בגין ביטוח בריאות‪.‬‬ ‫‪ .4‬לשאלות ובירורים ניתן לפנות ל‪:‬‬ ‫א‪ .‬מדור חשבונות סטודנטים‪ ,‬ל‪-‬יואב כהן‪-‬מלמד‪ ,‬בטלפון‪02-5882865 :‬‬ ‫ב‪ .‬משרדי "הראל‪-‬ידידים" המטפלים בביטוחי הסטודנטים‪ ,‬בטלפון‪03-6386216 :‬‬ ‫או‬ ‫במייל‪[email protected] :‬‬ ‫הר הצופים‬ ‫ירושלים ‪91905‬‬ ‫טלפון‪20-2330880 :‬‬ ‫פקס‪20-2338888 :‬‬ ‫בברכה‪,‬‬ ‫האגף למנהל תלמידים‪.‬‬ ‫‪Mount Scopus‬‬ ‫‪Jerusalem 91905 , Israel‬‬ ‫‪Tel. 972-2-5882342‬‬ ‫‪Fax. 972-2-5881143‬‬ ‫קבלת קהל‪:‬‬ ‫א'‪,‬ב'‪,‬ד'‪,‬ה' ‪11::: - 13:::‬‬ ‫יום ג' ‪10::: – 10:::‬‬ Application Form - Platinum Care The Hebrew University of Jerusalem 3015 Institution ___________________ Faculty or Department ______________________ A. Member’s Personal Details (Please print) Last name Address in Israel Home address Student No. Passport number First name Street Number Town Street Number Town Country Period of From Insurance E-mail Date of birth Zip code Telephone Zip code Telephone To ≤∞ ≤∞ Total number of days insured B. Declaration of Health Please answer the following no/yes questions by checking the appropriate box and provide any relevant details in the section below. Questions No Yes 1. Have you been hospitalized at any time? If so, when and for what reason? 2. Have you ever suffered or are you suffering now from: heart disease, cancer,cerebral disorder, nervous disorder, respiratory illness, digestive disorder, liver disease, kidney or urinary disorder, metabolic disorder, eye disease, ENT disease, dermatological or sexual disease or any other medical problem? 3. Have you at any time required an operation? 4. Have you at any time suffered an injury as a result of an accident? 5. Have you at any time suffered from any form of disability? 6. Have you suffered from any illnesses or are you aware of any health condition? 7. Are you on medication for any medical disorder? a. Are you pregnant? 8. For women b. Women’s diseases: menstrual cycle disorders breast disease (including lumps in the breast), uterus, ovaries, only: examinations for detection of a cancerous growth, mammography? Please specify. Details about the existing conditions. If you responded “yes” to any of the above questions, please note the question number, followed by details (including the date) of the condition. In addition, please attach a letter from your physician stating the current status of the condition. Details I declare and confirm that I have read the Terms & Conditions of the policy and its exclusions. I hereby declare that I am not suffering from any illness or accident. I am not handicapped. I am not undergoing any medical treatment of any kind. I do not, nor have I in the past suffered from any chronic medical condition (such as heart disease, high blood pressure, disability, etc. or a congenital disability, or a malignant disease). I am not aware of any need for medical treatment, hospitalization or surgery. I am aware that the coverage for worsening of a present illness under the Platinum Care policy is subject to the terms and exclusions of the policy. Renunciation of Medical Confidentiality: I, the undersigned, hereby give my permission to the health service provider and/or its medical institutions, as well as to all the doctors and other medical institutions and hospitals and/or to all the insurance companies and/or to any institute, other body and/or individual to provide Harel Insurance Company Ltd. (hereinafter "the Requestor") with all the details, without exception, and in the manner required by the Requestor regarding my state of health and/or any disease that I have suffered from in the past and/or that I am currently suffering from and/or that I will suffer from in the future, regarding the Harel policy, and I hereby release you from any obligation to safeguard medical confidentiality and renounce this confidentiality toward the Requestor. This Declaration of Renunciation binds me, my estate and Date my legal delegates and anyone who will come in my stead. This Declaration of Renunciation shall also apply to minors. D. Details of Health Insurance in Home Country – please check and/or complete the appropriate statement. Insurance company ______________________________________ policy number ____________________ †I have health insurance in my home country, but do not remember the details. †I have no health insurance in my home country. E. I hereby certify that all the information I have provided on this form is accurate and true. F. I am aware that the validity and scope of this insurance policy are determined by the health declaration that I have completed and signed, as well as by other factors. By signing this document, I am hereby responsible to inform the Harel Insurance Co. immediately of any change in my medical condition that occurs during the period between the date of my signature on the health declaration and the beginning of the insurance policy. Furthermore, without derogating from any legal right held by the Harel Insurance Co. in accordance with the terms of the policy, I am aware that this policy will in no event cover any new medical condition that occurs during the period between the date of my signature on the health declaration and the beginning of the insurance policy. Signature Contact Center: Harel-Yedidim, Division for Overseas Visitors and Students Beit Hakristal, 12 Hahilazon St., 8th Floor, Ramat Gan 52522 µ Tel: +972-3-6386216 µ Fax: +972-3-6874534 µ E.mail: [email protected] µ www.yedidim-health.co.il PLC-2 C. Personal Declaration Year ‰¢¯†††±Ø≤∞±≤ Question No. DECLARATION ‫חשבונות סטודנטים‬ ‫האגף‬ ‫למינהל תלמידים‬ Account Section Students Administration I HEREBY confirm that I am covered in Israel by the Department following Health Insurance/Medical Plan: _____________________________________ and have chosen not to purchase the health insurance policy offered at the Hebrew University. ‫הר הצופים‬ 91905 ‫י רושלים‬ 20-2330880 :‫טלפון‬ 20-2338888 :‫פקס‬ ___________________ __________________ Student No. Name (print clearly) ___________________ __________________ Date Signature Mount Scopus Jerusalem 91905 , Israel Tel. 972-2-5882342 Fax. 972-2-5881143 10::: – 10::: '‫יום ג‬ 11::: - 13::: '‫ה‬,'‫ד‬,'‫ב‬,'‫א‬ :‫קבלת קהל‬