Get Sho Pai

Owyhee Community Health Facility A governmental entity of the Shoshone-Paiute Tribes Sho-Pai Managed Care Program P. O. Box 130 Owyhee NV 89832 Phone 775 757-2415 Fax 775 757-3010 STUDENT HEALTH FORM 2009/2010 THIS SECTION IS TO BE COMPLETED BY THE STUDENT NAME LAST FIRST DATE OF BIRTH MI CHART NUMBER TRIBE ENROLLMENT NUMBER INSURANCE NAME PHONE NUMBERS NEEDED WHILE ATTENDING SCHOOL* HOUSING TELEPHONE CELL PHONE ADDRESS INSURANCE PHONE NUMBER EMERGENCY CONTACT INFORMATION PHONE RELATIONSHIP PERMANENT ADDRESS Mother father brother sister etc* LIST ALL DEPENDANTS WHO WILL ACCOMPANY YOU WHILE ATTENDING SCHOOL* DOB CHART I CERTIFY THAT CHECK OFF WHICH SEMESTER SPRING SEMESTER FALL SEMESTER IS ATTENDING THE ABOVE SCHOOL AS INDICATED. CHECK OFF FULL TIME STUDENT PART TIME STUDENT CREDIT HOURS Must Have 12 Credits to Qualify Per Semester DATE REGISTRAR S OFFICE SIGNATURE AUTHORIZATION FOR MANAGED CARE TO OBTAIN CREDIT HOURS SIGNATURE IS NEEDED BY REGISTRAR S OFFICE IN ACCORDANCE WITH 42C. F*R 136. 23 c STUDENT HEALTH FORM MUST BE ON FILE TO RECEIVE HEALTH SERVICES WHILE IN ATTENDANCE AT AN EDUCATIONAL INSTITUTION* RECEIVED BY MANAGED CARE ON APPROVED BY MANAGED CARE COMMITTEE ON Date DOWNLOADED FROM OCHF FORM FILES TITLE COLLEGE STUDENT FORM 2009-2010. O. Box 130 Owyhee NV 89832 Phone 775 757-2415 Fax 775 757-3010 STUDENT HEALTH FORM 2009/2010 THIS SECTION IS TO BE COMPLETED BY THE STUDENT NAME LAST FIRST DATE OF BIRTH MI CHART NUMBER TRIBE ENROLLMENT NUMBER INSURANCE NAME PHONE NUMBERS NEEDED WHILE ATTENDING SCHOOL* HOUSING TELEPHONE CELL PHONE ADDRESS INSURANCE PHONE NUMBER EMERGENCY CONTACT INFORMATION PHONE RELATIONSHIP PERMANENT ADDRESS Mother father brother sister etc* LIST ALL DEPENDANTS WHO WILL ACCOMPANY YOU WHILE ATTENDING SCHOOL* DOB CHART I CERTIFY THAT CHECK OFF WHICH SEMESTER SPRING SEMESTER FALL SEMESTER IS ATTENDING THE ABOVE SCHOOL AS INDICATED. CHECK OFF FULL TIME STUDENT PART TIME STUDENT CREDIT HOURS Must Have 12 Credits to Qualify Per Semester DATE REGISTRAR S OFFICE SIGNATURE AUTHORIZATION FOR MANAGED CARE TO OBTAIN CREDIT HOURS SIGNATURE IS NEEDED BY REGISTRAR S OFFICE IN ACCORDANCE WITH 42C. CHECK OFF FULL TIME STUDENT PART TIME STUDENT CREDIT HOURS Must Have 12 Credits to Qualify Per Semester DATE REGISTRAR S OFFICE SIGNATURE AUTHORIZATION FOR MANAGED CARE TO OBTAIN CREDIT HOURS SIGNATURE IS NEEDED BY REGISTRAR S OFFICE IN ACCORDANCE WITH 42C. F*R 136. 23 c STUDENT HEALTH FORM MUST BE ON FILE TO RECEIVE HEALTH SERVICES WHILE IN ATTENDANCE AT AN EDUCATIONAL INSTITUTION* RECEIVED BY MANAGED CARE ON APPROVED BY MANAGED CARE COMMITTEE ON Date DOWNLOADED FROM OCHF FORM FILES TITLE COLLEGE STUDENT FORM 2009-2010. O. Box 130 Owyhee NV 89832 Phone 775 757-2415 Fax 775 757-3010 STUDENT HEALTH FORM 2009/2010 THIS SECTION IS TO BE COMPLETED BY THE STUDENT NAME LAST FIRST DATE OF BIRTH MI CHART NUMBER TRIBE ENROLLMENT NUMBER INSURANCE NAME PHONE NUMBERS NEEDED WHILE ATTENDING SCHOOL* HOUSING TELEPHONE CELL PHONE ADDRESS INSURANCE PHONE NUMBER EMERGENCY CONTACT INFORMATION PHONE RELATIONSHIP PERMANENT ADDRESS Mother father brother sister etc* LIST ALL DEPENDANTS WHO WILL ACCOMPANY YOU WHILE ATTENDING SCHOOL* DOB CHART I CERTIFY THAT CHECK OFF WHICH SEMESTER SPRING SEMESTER FALL SEMESTER IS ATTENDING THE ABOVE SCHOOL AS INDICATED. CHECK OFF FULL TIME STUDENT PART TIME STUDENT CREDIT HOURS Must Have 12 Credits to Qualify Per Semester DATE REGISTRAR S OFFICE SIGNATURE AUTHORIZATION FOR MANAGED CARE TO OBTAIN CREDIT HOURS SIGNATURE IS NEEDED BY REGISTRAR S OFFICE IN ACCORDANCE WITH 42C. F*R 136. 23 c STUDENT HEALTH FORM MUST BE ON FILE TO RECEIVE HEALTH SERVICES WHILE IN ATTENDANCE AT AN EDUCATIONAL INSTITUTION* RECEIVED BY MANAGED CARE ON APPROVED BY MANAGED CARE COMMITTEE ON Date DOWNLOADED FROM OCHF FORM FILES TITLE COLLEGE STUDENT FORM 2009-2010.