Get Chowan University Wellness Center Fax Number Form

Completing the Chowan University Wellness Center Fax Number Form is a straightforward process that ensures your medical history is accurately recorded. This guide will provide you with detailed instructions to help you fill out the form online with confidence.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to access the Chowan University Wellness Center Fax Number Form and open it in your preferred editing tool.
2. Begin entering your last name in the designated field. Ensure clarity and accuracy.
3. Next, input your first name followed by your middle name, if applicable.
4. Provide your permanent address, ensuring that all components — street, city, state, and zip code — are filled out correctly.
5. Enter your date of birth in the specified format (MM/DD/YYYY) to ensure proper identification.
6. Indicate your gender by selecting the appropriate checkbox.
7. Complete the marital status field by selecting the applicable option.
8. List your area code and phone number for contact purposes.
9. Select the semester you are entering and the corresponding year from the options provided.
10. Fill in the name and address of your hospital or health insurance provider, including a contact telephone number.
11. Provide the name of the policyholder along with their social security number, if applicable.
12. Input the required policy or certificate number and group number for insurance verification.
13. Indicate whether your insurance plan is an HMO, PPO, or managed care plan by selecting the appropriate checkbox.
14. Fill in the emergency contact's name, relationship to you, and their contact information.
15. Complete the health history section by responding accurately to the questions regarding family health history and personal health conditions.
16. For any 'Yes' answers, provide additional explanations as required in the space provided.
17. Upon completion of all sections of the form, review your entries for accuracy.
18. Save your changes, then choose to download, print, or share the completed form as needed.

Start filling out your documents online today to ensure your health information is properly submitted!