This enrollment form should be completed by individuals who are 18 or older.

If you do not have insurance, please DO NOT submit this form until you call the HEALTHY CAMPUS UNINSURED PROGRAM AT 909-287-1150. A representative will help you understand your options and explain how to complete the following section.

By signing below...

• I confirm I am the patient or have the authority to sign on behalf of the patient. If you are signing on behalf of a minor, by signing below you are representing that you are authorizing the administration of the services on behalf of the minor.
• I consent to review my healthcare results via text or personal email and to communicate with my Provider via text or email. I understand that communications via text and email may be unsecured and have a greater risk of disclosure.
• I consent to this consultation and any associated physical and mental health screening. I understand that this and any treatment will be billed to your insurance by the Provider or its authorized group. You consent to Healthy Campus sharing your insurance information with a Provider for these purposes.
  If you do not provide accurate insurance information, you consent to discovery of insurance.
• I agree that by signing below, my signature will be applied to each of the documents at the links above.  By checking each box and signing below, I agree that I am signing each document with my signature for each person I am enrolling in the program.