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Florida Institute of Technology
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Holzer Health Center
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150 W. University Blvd., Melbourne, FL 32901-6975
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321-674-8078
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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 Pacic 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 benets 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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signature
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