Healthy 'Canes Employee Clinic - Registration Form (Coral Gables)

CLINIC SERVICES NOTE: Illness-related visits require a $10 clinic fee for benefits eligible UM employees. Annual physicals, flu shots and shingles vaccines do not require a clinic fee for benefits eligible UM employees. Annual physicals will be billed to the patient's insurance and will count towards the annual physical benefit under the patient's insurance plan. The patient will not be held responsible for any additional charges under the patient's insurance plan for the annual physical clinic visit. However, any services that follow the annual physical such as additional physician office visits, lab services and diagnostic testing will be billed by the provider rendering the service and will follow the benefits under the insurance plan. The annual physical includes an age and gender appropriate history and exam, orders for lab work, counseling and guidance, risk factor reduction and appropriate preventive screening tests based on age and gender. It does not include evaluation and management of abnormalities encountered or preexisting problems that require follow-up and management, nor does it include a well-woman exam (GYN exam/pap smear).

EMPLOYEE STATEMENT: Full-time and part-time benefits eligible University of Miami employees are eligible to receive care at this clinic. Non-benefits eligible employees, for example, a dependent, a student, a temporary/casual worker or a contract worker, are not eligible to receive care at this clinic. I attest that I am a full-time or part-time benefits eligible University of Miami employee. If I am found not to be a full-time or part-time benefits eligible University of Miami employee, I may be billed later for the full charge of the visit (approximately $150). Please review our privacy statement relating to information we collect, choice/opt-out, and correction/updating of personal information before proceeding.

Please review our privacy statement relating to information we collect, choice/opt-out, and correction/updating of personal information before proceeding.

* What is your UM ID number? (You must type in a response)
 
 
* What is your last name? (You must type in a response)
 
 
* What is your first name? (You must type in a response)
 
 
* What department do you work for? (You must type in a response)
 
 
* What is your contact phone number? (You must type in a response)
  Please include your area code
 
 
* What is your method of payment? (Select only one)
 
 
   
Once your form has been submitted, the information will be sent to clinic personnel and the screen will return to the registration form.