Online Health Insurance Card/Information Submission Form

Online Health Insurance Card/Information Submission Form
Thank you for attending our upcoming/recent Student Health & Wellness Center (SHWC) event!

Please complete the form below and upload the front/back of your health insurance card.

Fall 2024 Flu Vaccination Events
- 10/1: The WELL-Tampa Campus
- 10/2: MSC-Tampa Campus
- 10/16: JP Dorms-Tampa Campus
- 10/23: Library-Tampa Campus
- 11/1: “Defense Against the Dark Arts” @ SHWC-Tampa Campus
- 11/4: CAMLS
- 11/6: Athletics-Tampa Campus
- 11/13: Library-Tampa Campus
- 1/18: Honors College
- 11/20: MSC-Tampa Campus
Full Name*

First (Given) Last (Family)
Please select one*

I am a studentI am an employeeOther
Student U# (if applicable)
Birth Date*

MonthDayYear
Email Address*

Confirmation Email
Cell/Mobile #*
Question(s)
Do you have insurance?*

YesNo
Upload Insurance Card (front/back)

Browse Files

Cancelof
Insurance Company Name
Insurance Company Claims Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Insurance Company Phone Number
Member ID/Policy #
Member Group ID #
Insurance Type
Insurance Policy Holder’s Name

First NameLast Name
Relationship to Policy Holder’s
Policy Holder Date of Birth

MonthDayYear
Insurance Policy Holder’s Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Insurance Policy Holder’s Phone Number
Have you been to one of our clinics before?*

Yes, I am an existing patient.No, I am a new patient.
Please select which event you attended/will attend
Should be Empty: