New/Transfer Student-Athlete Medical Packet - University of Texas ...

Snort:InformationStudent-Athlete Name:SS#: DOB: Sex: Cell Phone#:Allergies:Medicine AllergieslFood Allergies:Medications Currently Taking:Medical Illnesses or Concerns:Emergency Contacts: 1: NamePrimary Care Physician:2: NamePhone# (Phone#_LPhone#*(__lInsurance Information(Please attach front/back eopy ofinsurance sard to this forrn)A, Policv Iloldgr (person whom the insurance is under)Name: Last:f irst:MT:ss#DOB:Phone: (tI).Address:StreetCityStste/Zip(tY)(c)B. Insura+celnformationName of Insurance Company:PPO?: YIN or HMO?:Y/NAddress:SfrcetCifyState/ZipClaims Services Phone #:orGroup# Policy # Member#Does your Insurance require: A second Opinion for surgery? yes_ No_:Pre-Authorization for services? yes No :Authorizafion For Release of In1.1":*,1*lti: :l fo-spltat,,physiciau, psvchotherapist or practitioner of the heafin! arts to tumish the bearer any informatiorL inctudinsbut not limited to oopies of medical records,_concemin! my pasq present.or future ptryiical, mental or emotional condition. I hereby waive'rnyphysician- and psychotherapist-patient privilege. t dsJauihorize the university ofrixas ut oala, and its desigrrated representatives toconsent o:r my behal{ to any medical,4rospital care or teatment to be rendered upon the advice of airy licerseO'pnysician. I agree to berosponsible financially for all necessary charges incurred by any hospitalization or treatrnent rendered pursuant io this authorization. Aphotostatic copy ofthis authorization shall be as effective and valid as tlre original.Student-Athlef e Signature Date Parents/Guardian Signature (under 18)