"Tour and Care" Tourist Gold Health Policy Sign Up

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Personal Details

Address where you are staying in Israel:
Email for personal notifications and mailings.
 

Health Statements

Please answer the questions below.

Section A: General Questions







Section B: Have you been diagnosed with a disease, syndrome, disorder related to one or more of the issues listed below:

















Billing Details


Parental Permission

I give permission for such diagnostic, therapeutic or emergency operative procedure as may be necessary to evaluate and treat -

HIPAA consent

I agree to waive my HIPAA (Health Insurance Portability and Accountability Act of 1996) rights, Israel’s patient privacy laws and all other applicable privacy provisions under the law, in order to allow the Harel Insurance Company medical providers, Egert and Cohen, CTAS medical providers to communicate with myself, each other, healthcare providers, parents, and school administrators regarding my/my childs health condition/s. This communication can be applicable via phone, email, WhatsApp, Skype, internet-based application or other forms of communication.

If sign-up is under 18:

Insurance Applicant’s Statement

  1. a. The information included in this document is required for your joining the policies and for all other matters and issues pertaining to the policies and the handling thereof. The Company and other companies of the Harel Group (Harel Insurance Investments and Financial Services Ltd. and its subsidiaries) and/or anyone on their behalf will make use of it, including the processing, storage and use thereof, for any matter pertaining to the policies and for other legitimate purposes, including by providing the information to third parties acting in the name and on behalf of the Harel Group.
    b. I/we hereby declare that all the answers are correct and complete and are provided out of my/our own free will.
    c. The answers specified in the Health Statement and any other information to be submitted to the Company as well as the Company's customarily prevailing terms and conditions in this matter shall be essential terms, conditions of the insurance contract between you and the Company, and constitute an inseparable part thereof.
    d. The Company may decide to either accept or reject the Application. For your information, the insurance contract shall come into force only after the Company issues a written confirmation of admission of all the insurance applicants.
  1. This medical insurance is subject to a qualification period of 48 hours.
  2. I am aware that the insurance contract shall come into force only after the Company issues a written confirmation of admission regarding the Insurance Applicant. In any case, the insurance period shall begin from the date of confirmation by the Insurer, as said above.
  3. Waiver of medical confidentiality: I/we the undersigned hereby give permission to an HMO (kupat holim) and/or its medical institutions and/or the IDF, and all the physicians and/or psychiatrists, the other medical institutions and hospitals, the National Security Council (MALAL) and/or the Ministry of Defense and/or any insurance company and/or to any other institution and entity, insofar as required in order to inquire and settle claims according to the policy and/or for the purpose of the procedure for examining my acceptance to the requested insurance plan to provide Harel including any information held by the Company and details with no exception and in the form required by those requesting it, about my/our health condition, about any illness I/we had in the past and/or that I/we are ill with now and/or will be ill with in the future and I/we release you from the duty of maintaining medical confidentiality and waiver this confidentiality towards the "requestor." This waiver binds me/us, my/our estate and my/our legal representatives and anyone that appears in my/our place. This waiver will also apply to my/our minor children.
  4. By enrolling in this policy, you are authorizing your insurance agent in the policy to submit and to receive on your behalf/and for you all notices and/or documents related to the underwriting and policy enrolment processes.