LAB INSURANCE FORM
Attention: UAlbany Student Health Services will send all laboratory specimens to LabCorp.
We chose this laboratory for the following reasons:
1. LabCorp participates with most health insurance carriers in accordance with your identified benefits.
2. If you do not have health insurance, LabCorp will provide a reasonable cash price.
3. If your insurance carrier does not participate with LabCorp, LabCorp will accept the Out of Network benefit.
Patient Name: ___________________________
________________________
(Print last name)
Date of Birth: ____/_____/____
(Print first name)
UAlbany ID#:_____________________________________________________
Tel. # (
) ______-_______
U.S. Billing Address:
_____________________________________________________________________________________________
Street
City
State
Zip
U.S. Permanent Address (Please note this billing address will be used at the semester end:
May 1 (Spring)/Dec 1 (Fall)):
_____________________________________________________________________________________________
Street
City
State
Zip
Name of Insurance Company__________________________________ Tel. # (
) _______-________
Policy / ID Number_____________________________________
Group Number (if available) ______________________________
Policy Owner’s Name____________________________________
(Print last name)
______________________________
(Print first name)
Please be sure the above information is accurate.
 The laboratory bill is the responsibility of the student. The student is responsible for knowing what
laboratory services their insurance covers.
 In the event your insurance company does not cover these expenses you will receive a bill from LabCorp.
I have read the above and agree with its terms.
__________________________________________
_____________________
Signature
Date
Division of Student Affairs
Student Health Services
400 Patroon Creek, Suite 200, Albany, NY 12206
PH: 518-442-5454 FX: 518-442-5444
www.albany.edu
Document1
Revised 8/15