department of athletics policies & procedures - UNC Wilmington ...

Is this insurance policy an: HMO Yes / No PPO Yes / No
Effective Date of Policy
**If yes please see reverse side
Expiration Date of Policy
Policy # Group # Authorization Phone #
Policy Limit(s) Policy Deductible Policy Co-Pay
List any special instructions or required authorizations needed prior to treatment
Insurance Information Release Form
Permission is granted to the University of North Carolina Wilmington Department of Athletics to contact and receive
information from my private insurance company described on the Insurance Notification Form pertaining to payments
and/or action taken by my personal insurance company.
Student-Athlete Signature
Date
Parent/Guardian Signature (if under 18 yrs. of age)
Date
296