20200741
Page 1 of 5
Florida Institute of Technology
Holzer Health Center
150 W. University Blvd., Melbourne, FL 32901-6975
321-674-8078
Fax 321-725-5967
~RIDA TECH
~
Primary Care
FLORIDA'S STEM UNIVERSITY'
NEW PATIENT INFORMATION
PATIENT
Last Name__________________________________________________________
First Name__________________________________________________________
Email Address_______________________________________________________
Florida Tech Mailbox Number _________________________________________
Address ____________________________________________________________
City ________________________________________________________________
State________________________________ ZIP__________________________
Cell or Home Phone__________________________________________________
Student ID/SSN _____________________________________________________
Employer ___________________________________________________________
Work Phone_________________________________________________________
Date of Birth ________________________________________________________
Emergency Contact Name____________________________________________
INSURED PARTY
Company ___________________________________________________________
Policy No. ___________________________________________________________
Group No.___________________________________________________________
Policy Holder ________________________________________________________
Policy Holder DOB ___________________________________________________
Phone ______________________________________________________________
Phone ______________________________________________________________
Primary Care Physician ______________________________________________________________________________________________________________________
Race: White American or Alaska Native Asian Black or African American Native Hawaiian or other Pacic Islander Other
Ethnicity: Non Hispanic Hispanic or Latino
Marital Status: Single Married Separated Divorced Widowed
Consent for Treatment: The undersigned authorizes the Florida Tech O.A. Holzer Health Center to provide treatment including X-rays, blood withdrawal, local
anesthesia, intravenous solutions and the performance of which the provider considers necessary and proper in the treatment of the above named patient.
Cancellation/ No Show Policy: I, the undersigned, understand the Health Center requires a 24 hours’ notice of cancellation. Patients who repeatedly
cancel or do not show for their schedule appointments may lose eligibility for services and may be referred to an o-campus provider.
Release of Records: I hereby authorize the provider to furnish insurance companies with any information concerning my treatment that may be requested,
including photocopies from my patient records as necessary for completion of my claim or as may be requested by law. I further authorize the provider to
furnish information from my records pertaining to the treatment as requested by other doctors or medical care facilities for continued care and treatment.
Payment Agreement: I, the undersigned, understand that I am responsible for all charges for treatment received regardless of insurance coverage. I
understand that the provider cannot accept responsibility for collecting any insurance claim or negotiating any settlement on a disputed claim. Provider
reserves the right to decline further services to the patient for non-payment. Patient accounts are due at the time treatment is given unless other
arrangements are made in advance. A charge of $27.50 will be charged on all RETURNED CHECKS.
I, the undersigned, assign benets payable for physician services to the physician or organization furnishing the services and authorize the physician
group/organization to submit a claim to my health insurance carrier on my behalf.
Signature of patient (or parent, if a minor)
__________________________________________________________________ Date______________________________
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20200741
Page 2 of 5
Florida Institute of Technology
Holzer Health Center
150 W. University Blvd., Melbourne, FL 32901-6975
321-674-8078
Fax 321-725-5967
~RIDA TECH
~
Primary Care
FLORIDA'S STEM UNIVERSITY'
NEW PATIENT INFORMATION
HOLZER STUDENT HEALTH CENTER POLICY
I understand that any procedures, in-clinic testing, laboratory/blood work or X-rays will be billed to my personal health insurance.This includes in-clinic
testing for urinary tract infections, strep throat, pregnancy, inuenza and mononucleosis. I am nancially responsible for any medical services not covered
by my health insurance. I acknowledge that the insurance information I have provided is accurate and complete to the best of my knowledge.
I understand it is my responsibility to know the coverage and limitations of my own insurance, whether it is through my parents or the university.
Signature_______________________________________________________________________________________________ Date______________________________
UNITED HEALTHCARE—STUDENT RESOURCES (STUDENT HEALTH INSURANCE PARTICIPANTS)
Your insurance requires a deductible each academic year (i.e., patient is responsible for the rst $75 of medical expenses). Please call United Healthcare
insurance company for more information or access uhcsr.com for Florida Tech student health insurance information.
Signature_______________________________________________________________________________________________ Date______________________________
Your Florida Tech student health insurance representative can be reached at 321-674-8080.We encourage you to consult your student medical plan for
further information regarding coverage and exclusions before calling.A student health insurance booklet is available online.
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20200741
Page 3 of 5
Florida Institute of Technology
Holzer Health Center
150 W. University Blvd., Melbourne, FL 32901-6975
321-674-8078
Fax 321-725-5967
~RIDA TECH
~
Primary Care
FLORIDA'S STEM UNIVERSITY'
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
Name ______________________________________________________________
List of current medications
Allergies to medications______________________________________________
List previous surgeries/hospitalizations________________________________
Have you had a history of any of the following:
HEALTH HISTORY
Birth Date___________________________________________________________
Headaches
Seizures
Anemia
Tuberculosis
Skin Problems
Sickle Cell Disease
Heart Problems
Liver Disease
Urinary Problems
STDs
Anorexia
Depression
Eye Problems
Blood Clots
Diabetes
Stomach/Bowel Problems
High Blood Pressure
Asthma/Lung Problems
Cancer
Gall Bladder Disease
Allergies
Blood Disease
Bulimia
Anxiety
Additional concerns _________________________________________________________________________________________________________________________
Have you ever been treated for mental illness or emotional problems?  Ye s No
Do you use Tobacco?  Yes No  Alcohol?  Ye s No  Drugs?  Ye s No
Has anyone hit you or struck you in the last 18 months?  Yes No
Are there any diseases that run in your family?  Yes No  If yes, please list________________________________________________________________
20200741
Page 4 of 5
Florida Institute of Technology
Holzer Health Center
150 W. University Blvd., Melbourne, FL 32901-6975
321-674-8078
Fax 321-725-5967
~RIDA TECH
~
Primary Care
FLORIDA'S STEM UNIVERSITY'
____________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
CONSENT AGREEMENT
Consent to the Use and Disclosure of Health Information for Treatment, Payment or Health Operations
I, ____________________________________ (patient name), understand that as part of my health care, this practice originated and maintains health records
describing my health history, symptoms, examinations, test results, diagnoses, treatments and any plans for future care or treatment. I understand that this
information serves as:
A basis for planning my care and treatment
A means of communication among the many health professionals who contribute to my care
A source of information for applying my diagnosis and surgical information to my bill
A means by which a third-party payer can verify that services billed were actually provided
A tool for routine health care operations such as assessing quality and reviewing the competence of health care professionals
I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures.
I understand that the organization reserves the right to change their notice and practices and prior to implementation will mail a copy of any revised notice
to the address I’ve provided. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry
out treatment, payment or health care operations and that the organization is not required to agree to the restrictions requested. I understand that I may
revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon.
I wish to have the following restrictions to use or disclosure of my health information
________________________________________________________________
I fully understand and  accept  decline the terms of this consent.
Signature of patient or legal representative _________________________________________________________________ Date______________________________
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20200741
Page 5 of 5
Florida Institute of Technology
Holzer Health Center
150 W. University Blvd., Melbourne, FL 32901-6975
321-674-8078
Fax 321-725-5967
~RIDA TECH
~
Primary Care
FLORIDA'S STEM UNIVERSITY'
CONSENT FOR COMMUNICATION
AND/OR DISCLOSURE
I request the following alternatives or limitations relating to communications directed to me by my health care provider or employee
of PREMIER PRIMARY CARE.
Do we have your permission to call you at home or at the number you have given?  Yes No
If yes, may we leave the following information on your answering machine or voice mail?
Appointment Information  Ye s No
Billing Information  Ye s No
Medical Information  Yes No
May we call you at work?  Yes No
If yes, may we leave the following information on your work answering machine or voice mail?
Appointment Information  Ye s No
Billing Information  Ye s No
Medical Information  Yes No
I give my permission to share the following information with the person(s) named below:
Name ____________________________________________________________________ Relationship ___________________________________________________
Appointment:  Yes No  Billing:  Ye s No  Medical:  Ye s No
Name ____________________________________________________________________ Relationship ___________________________________________________
Appointment:  Yes No  Billing:  Ye s No  Medical:  Ye s No
Name ____________________________________________________________________ Relationship ___________________________________________________
Appointment:  Yes No  Billing:  Ye s No  Medical:  Ye s No
Name ____________________________________________________________________ Relationship ___________________________________________________
Appointment:  Yes No  Billing:  Ye s No  Medical:  Ye s No
Patient Signature________________________________________________________________________________________ Date______________________________
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