UHealth - University of Miami Health System

International Patients Form

Complete all information requested below. Without this information, it will not be possible to arrange the appointment(s) you are requesting.

Once you’ve submitted the appointment form, fax copies of your insurance card (front and back), your passport and all pertinent medical reports and records to 305-243-9101. These documents may also be scanned and submitted via email to uhealthinternational@med.miami.edu.

For more information, please call 305-243-9100 or visit the UHealth International website.

If you are experiencing symptoms that are urgent in nature please contact your primary care physician or your nearest urgent care facility.

Patient Information

Have you been treated by our doctors before?

Gender:

Date of Birth

Emergency Contact

Parent Information

!

Parents of patients under the age of 18: parent must provide parental full name and date of birth in the section below.

Parent Date of Birth

Insurance Information

Your insurance company must have an office in the United States.

Do you have health insurance that will cover your services at UHealth International?

Insurer Contact Information

Payment Information

Same as patient information?

Appointment Information

Referral Information

:

Referring Doctor Information

Service Agreement

Information collected from this website or provided on any form you have submitted through the website is used only in conjunction with an expressed interest by the user in obtaining additional information about the University of Miami's physician practice or services. It does not create any type of relationship between the individual providing the information and the University of Miami or any of its physicians. This information is not considered Protected Health Information (PHI) and will be used to contact you because you have requested that you be contacted. In addition, information provided on the website or in any response to you is not and cannot be considered medical advice or treatment. The University of Miami will not be liable for and you will release and hold them harmless from any claims and/or any direct, indirect, consequential, special, exemplary, or other damages arising therefrom. Please consult with your doctor for medical advice or treatment for any condition you may have. If you are experiencing a medical emergency, call 911 and/or go to the nearest emergency room.

Once you've submitted the appointment form, fax copies of your insurance card (front and back), your passport and all pertinent medical reports and records to 305-243-9101. These documents may also be scanned and submitted via email to uhealthinternational@med.miami.edu.

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