Insurance Card

Insurance Card
Although Hamline Health Services does not bill insurance for office visits, we may request labs to help with your care, any incorrect or incomplete information may result in your insurance company denying a claim. If a claim is denied Hamline Health Services will bill to your student account any denied claims.
Name *

First Name Last Name
Student ID # *
Subscriber Name: (Who pays for the insurance?) *

First Name Last Name
Your relationship to the subscriber? *
Subscriber Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Subscriber Phone Number *

Area Code Phone Number
Subscriber Date of Birth *

Month Day Year
Date
Front of Insurance Card *

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Cancel of
Back of Insurance Card *

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Cancel of
Should be Empty: