STUDENT MEDICAL & COUNSELING CLINIC
INSURANCE FORM
(Please Print Clearly)
STUDENT INFORMATION
Last Name:
First:
Is this your legal name?
 Yes
 Mr.
 Mrs.
Middle Initial:
If not, what is your legal name?
 Miss
 Ms.
Marital status (circle one)
Single / Married / Divorced / Separated / Widow
(Preferred name):
DOB:
Social Security Number :
Cell Phone Number:
 No
Age:
/
Current/Local Street Address:
-
-
(
Sex:
 F  M  Other
/
)
Is it okay to leave a message at the above number?  YES  NO (Check One)
We use text messaging for appointment reminders. Can we text you for all appointment reminders?  YES  NO
Standard text messaging rates apply based on the subscriber’s plan with their mobile phone carrier.
P.O. Box:
City:
State:
Email Address:
Emergency Contact:
Relationship:
(Check One)
ZIP Code:
Emergency Contact Phone No.:
(
)
INSURANCE INFORMATION
(Please give your insurance card(s) to the receptionist.) FAILURE TO COMPLETE FULLY MAY LEAD TO PAYMENT REJECTION
Primary Insurance:
Subscriber’s Name:
Subscriber’s Address (if different from above):
Home Phone No.:
(
Occupation:
Employer:
Employer address:
(
 Spouse
Patient’s relationship to subscriber:
Subscriber’s SS Number: (If used as
policy #)
 Child
/
)
 Self
Policy Number:
DOB:
)
Employer Phone No.:
Group Number:
Co-payment:
/
$
Secondary Insurance (if applicable):
Subscriber’s Name:
Subscriber’s Address (if different from above):
Home Phone No.:
(
Occupation:
Employer:
Employer address:
(
 Spouse
Patient’s relationship to subscriber:
Subscriber’s SS Number: (if used as
policy #)
 Child
/
)
 Self
Policy Number:
DOB:
)
Employer Phone No.:
Group Number:
Co-payment:
/
$
METHOD OF PAYMENT
There may be charges at time of service (co-pay), please indicate below your preferred method of payment.
 Credit/Debit
 Connection Card
 Student Account
SID #:
If for any reason your insurance doesn’t pay for the incurred charges, you will be held responsible to pay for those
charges out of pocket. ____________ (initials)
NOTICE OF PRIVACY: All Information on this form is considered confidential and will not be shared with any outside party unless
consent is provided by the student to the Student Medical & Counseling Clinic.
Student Medical & Counseling Clinic
400 E. University Way, Ellensburg, WA 98926-7585
Counseling (509) 963-1391 Medical (509) 963-1881 Fax (509) 963-1886
Staff Initials:________
STUDENT MEDICAL AND COUNSELING CLINIC
DEMOGRAPHICS FORM
(Please Print Clearly)
Student ID:
Name: (Last, First & Middle Initial)
MEDICAL HISTORY
Drug Allergies (if known):
Please list significant illness, injuries, surgeries or other hospitalizations:
Approximate Date(s)
Medical Condition(s)
Yes 
Do you take routine medications?
No 
If yes, what are they? ____________________________________
____________________________________
(Attach list if needed)
____________________________________
Yes 
Do you take herbal supplements?
No 
If yes, what are they? ____________________________________
____________________________________
(Attach list if needed)
____________________________________
Please check the following boxes if you or a close relative have or had any of the following:
You




Relative




You
Diabetes
Stroke
Arthritis
Cancer




Relative




You
Heart Trouble
Depression
Suicide
Tuberculosis




Relative




You
Anxiety
Stomach Ulcers
High Blood Pressure
Asthma/Allergy




Relative




Thyroid Disease
Alcohol/Drug Dependency
Eating Disorder
Concussion(s)
Do you smoke, chew, dip or use any kind of tobacco product?
Yes 
No 
How much? _______________________
Consume caffeine?
Yes 
No 
How much? _______________________
Do you drink alcohol?
Yes 
No 
How much? _______________________
Do you use non-prescribed or illegal drugs?
Yes 
No 
How much? _______________________
Has controlling alcohol or drug use been a problem for you?
Yes 
No 
 The CWU Student Medical and Counseling Clinic (SMaCC) provides primary care for students enrolled at CWU. Services are limited to outpatient
care. There are lab and X-ray facilities on the premises. Physicians, PA-Cs, Nurse Practitioners, Nurses and Lab and X-Ray Technicians provide
services. A Medical and Counseling Clinic charge is assessed to your account each quarter for students taking more than a specific number of credit
______ hours. Those students taking less than this number of hours are assessed this charge during their first visit of each quarter. All medical information and
Initials records are confidential and will be released only with your authorization or as detailed in the Notice of Privacy Practices.
 There are additional charges for lab tests, X-rays, certain physical exams, procedures and supplies. If you have questions, please ask the SMaCC
______ staff. You are responsible for any charges from the SMaCC. Charges will be billed to your student account, insurance, and/or appropriate responsible
Initials party.
______ I certify that all of the information above is to the best of my knowledge and belief true, correct and complete.
Initials
CONSENT FOR TREATMENT: I consent to treatment, health care operations and responsibility for billed procedures at the CWU:SMaCC.
ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICE: I have received and had the opportunity to review the CWU:SMaCC Notice of Privacy Practice.
Signature: ____________________________________________________________________
Date: __________________________________
Student Medical & Counseling Clinic
400 E. University Way, Ellensburg, WA 98926-7585
Counseling (509) 963-1391 Medical (509) 963-1881 Fax (509) 963-1886
Staff Initials:________