Health Fee Authorization Form

Health Fee Authorization Form

By completing this form, you will be authorizing the Office of Student Accounts and Billing Services to assess your student account for the Health Fee. Once this form is completed the health fee will be added to your student account and will be able to be paid through Banweb. For any questions regarding how to make a payment please visit the Office of Student Accounts Website at https://www.westga.edu/student-services/studentaccounts/payment-of-tuition-fees.php

If you have any questions about this form or any concerns please contact the Student Account office at studentaccounts@westga.edu or by phone at 678-839-4737.

Date Form Completed*

Student ID*

Last Name*

First Name*

Semester to add Health Fee*

Select

If you are requesting the health fee, be added for the SUMMER semester and you are NOT registered for SUMMER course(s) you are required to have been enrolled in the previous SPRING semester and currently be enrolled for the upcoming FALL semester. If you do not meet BOTH requirements your request will be denied.*

If you have questions about this requirement you can contact Health Services at 678-839-6452.

Select

I understand this per semester fee must be paid in order for me to receive services at the Student Health Center.*

I understand the Health Fee will be based on my total credit hours but will not exceed $101.00 per semester. I understand the Bursar’s Office will determine the amount to be charged.*

I understand there may be additional fees associated with the services provided at the health center. I may provide payment at the time of my visit or have those fees charged to my student account.*

I understand that a Fee Payment Hold will be placed and remain on my UWG account until the Health Fee and any other Health Services related charges are paid.*

I authorizes the Office of Student Accounts and Billing Services to charge me the Student Health Fee*

Type your full First and Last name as it appears on your student record if you are in AGREEMENT with the above statement. If you have any concerns or questions about this form please contact the Office of Student Accounts and Billing Services by email - studentaccounts@westga.edu or by phone at 678-839-4737.

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