PLEASE ENCLOSE A COPY OF YOUR INSURANCE CARD, FRONT BACK! by tamir13

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									Patient / Athlete Information
Patient / Athlete’s Full Name: ___________________________________________________ Sport: _________________________
Patient / Athlete’s Home Address: ______________________________________________________________________________
__________________________________________________________________________________________________________
          City                                   State                                           Zip
Patient / Athlete’s Date of Birth: ____________________ Patient / Athlete’s Social Security # : ______________________________
Gender: M F               Martial Status: Single Married    Race: Caucasian African American Asian Other
Cell phone #: _____________________________________________


Parental Information (All blanks must be completed, if not applicable, put N/A)
Father’s Name: _____________________________________________________________________________________________
Father’s Date of Birth: __________________________ Father’s Social Security #: ______________________________________
Father’s Home Address: : _____________________________________________________________________________________
__________________________________________________________________________________________________________
          City                              State                                       Zip
Father’s Place of Employment: ________________________________________________________________________________
Father’s Home Phone: _______________________________ Father’s Work Phone: ______________________________________
Father’s Cell Phone: _________________________________ Email: __________________________________________________

Mother’s Name: _____________________________________________________________________________________________
Motherr’s Date of Birth: ___________________________ Mother’s Social Security #: _____________________________________
Mother’s Home Address: : _____________________________________________________________________________________
__________________________________________________________________________________________________________
         City                               State                                       Zip
Mother’s Place of Employment: _________________________________________________________________________________
Mother’s Home Phone: _______________________________ Mother’s Work Phone: _____________________________________
Mother’s Cell Phone: _________________________________ Email: __________________________________________________


Insurance Information (All blanks must be completed)
If uninsured please contact Elizabeth Spitz at 864-597-4459 or spitzes@wofford.edu
Insurance Company: ___________________________________________ Policy #: ______________________________________
Insurance Company Address:
_______________________________________________________________________________________________________
                   Street                    City                                 State           Zip
Insurance Company Phone: _________________________________________________________________________________
Name of the Policy Holder: ________________________________ Relationship to Patient / Athlete: _______________________
Policy Holders Date of Birth: _____________________Policy Holders Social Security Number: __________________________
Policy Deductible: $_________________________ (This is a monetary amount you are required to pay before you are eligible for
medical benefits under your policy. You MUST answer this question!)

Is the Policy an HMO? ( ) Yes         ( ) No
If yes, please provide the following information and contact Elizabeth Spitz at 864-597-4459 or spitzes@wofford.edu
Name of Primary Care Physician: ______________________________________________________________________________
Physician’s Phone for Authorization: ____________________________________________________________________________



The above information is correct to the best of my knowledge. I understand that if I have provided false information to Regional
Sports Medicine at Wofford that I, or my parent/guardian, may be responsible for any and all costs associated with any athletic injury I
receive while participating in intercollegiate athletics at Wofford.

Athlete Signature:____________________________________________ _________ Date: ________________________________

Parental signature is required only if the athlete is under 18.

Parental Signature: ____________________________________________________ Date: ________________________________




PLEASE ENCLOSE A COPY OF YOUR INSURANCE CARD, FRONT & BACK!

								
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