Silver Valley Unified School District

We are updating our records and requesting your child’s health insurance information.

Student First Name

Student Last Name

Student DOB

Student ID

Insurance Carrier

Insurance Member ID

Your First Name

Your Last Name

Your Email

Your Phone

I consent to the release of my child’s health records and/or access to benefit information for the purpose of billing

I DO NOT consent to the release of my child’s health records and/or access to benefit information for the purpose of billing

Please Sign Below