On-Campus Health Services Fee Opt-In Agreement

For the academic year 2018-2019, continuing undergraduate students as well as new and continuing graduate students are eligible to receive on-campus health services, which is provided by a third party provider, SP Health Clinic, at the Health Services Office (UB 210E). This non-refundable Health Center Fee is $100 per semester for unlimited visits while the Health Services Office is open 16 hours a week during the fall 2018 semester:

Mondays: 8:00AM - 12:00PM
Tuesdays: 9:00AM - 1:00PM
Wednesdays: Closed
Thursdays: 9:00AM - 1:00PM
Fridays: 9:00AM - 1:00PM

There will be no co-pay at the time of visit, and health insurance is not required to be seen. For a list of conditions that will be evaluated as part of the program fee, and for the lab fees (if applicable) that will be paid during the office visit, go to www.hpu.edu/healthcare for details. Any other conditions or diagnosis falling outside the scope of these common illnesses will be subject to referral to an off-campus medical provider, based on the clinical staff’s judgement.

Deadline to submit for Fall 2018: September 17 (5pm)

Deadline to submit for Spring 2019: February 4 (5pm)

Name Name First Last
HPU ID#
Phone Phone - ### - ### ####
HPU Email
Residence:

Residence: Hawaii Loa Campus Waterfront Lofts Off-Campus
On-campus room number:
Address if off-campus: Address if off-campus:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Please select one of the following options:

Please select one of the following options: I would like to opt-in ONLY for Fall 2018 for $100 I would like to opt-in ONLY for Spring 2019 for $100 I would like to opt-in for Fall 2018 ($100) AND Spring 2019 ($100)
I understand that this Agreement is for the specified term listed above and is non-refundable. I will make my on-campus Health Center Fee payment in accordance with University policy, at such time that tuition and fees are due for fall and spring terms. I agree to all of the terms and conditions above and have received and reviewed all applicable University policies referenced herein.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY
If student is less than 18 years of age:

I represent that I am the parent or guardian of the above student, and am legally authorized to bind the participant to the terms of this agreement.

Print Parent/Guardian Name:
Parent/Guardian Signature:

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY