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

PLEASE COMPLETE THE FOLLOWING INFORMATION IF YOUR SON/DAUGHTER IS COVERED
UNDER YOUR GROUP INSURANCE AND IT IS AN HMO OR PPO.
Please provide the name, address, and phone numbers of your student-athlete’s primary care physician within your
required network. The primary care physician will control the approval of all necessary “referrals” to specialist(s) if
needed.
Primary Insurance:
Physician’s Name
Address
City/State/Zip
Phone ( ) Fax ( )
Secondary Insurance:
Physician’s Name
Address
City/State/Zip
Phone ( ) Fax ( )
Yes, I have seen my primary care physician and am an established patient in his/her office (as noted above).
No, I have NEVER seen my primary care physician. I know that I must see him/her before I come to UNCW
for my insurance to be valid. I will make an appointment to establish myself as a “valid” patient in his/her office
prior to coming to UNCW and make him/her aware of my “out of town” residency in Wilmington, North Carolina
while attending UNCW.
No I have NEVER seen my primary care physician and will be choosing a primary care physician in
Wilmington, North Carolina. I will make an appointment with a network primary care physician within 30 days of
arriving in Wilmington and will notify the Athletic Training Department of who that physician is.
Other – Please Explain
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