Deadline for all Pre-Matriculation requirements is July 1st.

Pre-Matriculation Checklist

Review this document in its entirety. Complete, sign, and submit the following documents together to

med.admissions@fiu.edu. No photographs of required documents are accepted. Incomplete packets will not be

accepted.

____ Student Information Form

____ Measurement Submission Form

____ Personal Information Form

____ Residency Form and Residency Identifiers

____ Photographic/Film Consent and Release Form

____ Medical Student Handbook Student Consent Agreement Form

____ Pre-Matriculation and Retention Requirements

____ Tuition Payment Student Policy

____ VECHS Waiver FormI confirm that all mentioned above are enclosed in this packet. Failure to enclose all required documents will

result in a delay of matriculation.

Signature:_______________________________ Panther ID #:_______________________

Print Name: _____________________________ Date:_____________________________

Please also be sure to complete the following items:

Undergraduate/Graduate Transcript(s) to be mailed directly to:

FIU HWCOM Office of Admissions 11200 S.W. 8 Street, AHC2 390W2 Miami, Florida 33199

You must submit transcripts from EACH institution ever attended. We do not have access to the

transcripts you previously sent to AMCAS.

Be sure your degree has posted prior to requesting the official transcript.

E-transcripts are accepted; please send e-transcripts to med.admissions@fiu.edu.

Drug Screening at http://www.fiumedicinescreening.com/

Level I Background Check - You should have received an email directly from AAMC when you were accepted.

There is no cost to complete as you have already paid for this through AMCAS.

Level II Background Check at http://www.fiumedicinescreening.com/

Online Payment for Disability Insurance, N-95 Respirator Mast Fit Testing, and White Coat at

http://payment.medicine.fiu.edu/osa/studentdues/ Period to Pay- Pre-matriculation.

RSVP for White Coat Ceremony at http://go.fiu.edu/whitecoat

Student Information Form

All OFFICIAL biographic/demographic information MUST be correct on my.fiu.edu at all times during medical school. Please log on to http://my.fiu.edu and update the following information:

Click each tab and ensure all your information is correct.

1. Official Name (as it should appear on your diploma and all other documents) a. If you need to change your name and/or permanent address please fill out the Change of Name and

Address form (http://medicine.fiu.edu/_assets/docs/change-of-name-and-address.pdf) attach your supporting documents, and send it to comregistrar@fiu.edu.

2. Addresses a. Permanent (to change see above) b. Local (local address can be changed by you on my.fiu.edu)

3. Phone Numbers

a. Cellular Phone and Home Phone

4. Alternate Email

5. Emergency Contact a. If you do not list an emergency contact prior to the start of classes, you will not be allowed to

participate in any educational or clinical activities until you have done so.

I acknowledge that I have logged on to my.fiu.edu and updated my biographic/demographic information as listed above.

Signature:_______________________________ Panther ID #:_______________________ Print Name: _____________________________ Date:_____________________________

Measurement Submission Form

The coats follow unisex sizing (XXS-5X). For the best possible fit ladies should reference their dress size and

men their jacket size. Indicate the size of the white coat you would like to order using the charts listed above.

Your legal name (as listed on AMCAS) will be stitched on the coat.

Name: _______________________________________________________________________________

Men’s Size: _____________________________ or Women’s Size: _____________________________

Height: _____________________________

Select your t-shirt size:

X-Small Large Small X-Large Medium XX-Large

Please spell your name phonetically.

_____________________________ _____________________________ First Name Last Name I request that the FIU Herbert Wertheim College of Medicine order a white coat of the size indicated above. I confirm that I have already submitted payment at http://payment.medicine.fiu.edu/osa/studentdues/ Signature:_______________________________ Panther ID #:_______________________

Print Name: _____________________________ Date:_____________________________

Personal Information Form

Print Name:_______________________________ Panther ID #:_______________________

Date: ____________________________________

Parent:

Name: ___________________________________

Relationship: ______________________________

Address: _________________________________

Home Phone: _____________________________

Cell Phone: _______________________________

Email: ___________________________________

Spouse/Partner:

Name: ___________________________________

Relationship: ______________________________

Address: _________________________________

Home Phone: _____________________________

Cell Phone: _______________________________

Email: ___________________________________

Parent:

Name: ___________________________________

Relationship: ______________________________

Address: _________________________________

Home Phone: _____________________________

Cell Phone: _______________________________

Email: ___________________________________

Other:

Name: ___________________________________

Relationship: ______________________________

Address: _________________________________

Home Phone: _____________________________

Cell Phone: _______________________________

Email: ___________________________________

If your residency status has been determined to be “Non-Resident for Tuition Purposes” and you believe this determination to be in error, you must read this document carefully, determine which category or categories apply to you, and submit a completed and signed Information for Residency Classification form (on the other side of this form) along with appropriate documentation to establish your Florida residency. Submission of requested documentation does not guarantee the conferment of Florida residency status. Act now to support your Florida residency claim. Do not wait until classes begin to establish your residency! Failure to establish Florida residency in accordance with Florida Administrative Code 6C-7.005 and Florida Statute 1009.21 before the first day of classes will result in automatic classification of “Non-Resident for Tuition Purposes,” which will result in your being subject to and liable for the higher out-of-state tuition fees for all courses taken that term.

Documentation Recommended for Establishment of Florida Residency CATEGORY A CATEGORY B CATEGORY C CATEGORY D CATEGORY E CATEGORY F CATEGORY G CATEGORY H CATEGORY I CATEGORY J CATEGORY K CATEGORY L Independent Dependent (on

parents or legal

guardian)

Dependent (on adult relative

other than legal

guardian)

Married to a Florida

resident

Previously enrolled at a Florida state

institution and classified as a

Florida resident/

Enrolled at Florida state

institution and abandoned

Florida domicile less

than 12 months ago.

Resident Alien/ Employment

Authorization/ Visa type card

holders eligible for In-State

tuition.

Member of Armed

Services

Full-Time Instructional or Administrative

employee

Latin American/ Caribbean

Scholarship program

Florida Prepaid College Program

Isthmus of Panama

Full-time employee of state agency

Information for residency

classification form

completed and signed by applicant

Information for residency

classification form completed and signed by

applicant’s parent or legal

guardian.

Information for residency

classification form completed and signed by

applicant’s adult relative.

Information for residency

classification form completed and signed by

applicant’s spouse.

Information for residency

classification form completed

and signed.*

Information for residency

classification form completed

and signed.*

Information for residency

classification form completed

and signed.*

Information for residency

classification form completed

and signed.*

Information for residency

classification form completed

and signed.*

Information for residency

classification form completed

and signed.*

Information for residency

classification form completed

and signed.*

Information for residency

classification form completed

and signed.*

and and and and and and and and and and and and

Applicant’s: Driver’s license. Vehicle

registration. Federal

income tax form.

Homestead, deed, or lease

agreement. Letter (on letterhead) signed by employer.

Student’s: birth certificate.

and/or

Legal

guardianship paperwork

and

Parent or legal

guardian’s: Driver’s

license. Vehicle registration.

Federal income tax form.

Homestead, deed,

or lease. Letter (on letterhead)

signed by employer of

parent or guardian.

Relative’s: Federal income tax forms from

the last five years. Driver’s

license. Vehicle registration. Homestead,

deed, or lease. Letter (on letterhead) signed by

employer of relative.

Certified marriage

certificate.

and

Spouse’s: Driver’s

license. Vehicle registration.

Federal income tax form.

Homestead, deed, or lease.

Letter (on letterhead) signed by spouse’s employer.

Letter from former

institution that indicates you

are qualified for instate tuition. If your nation of citizenship is other than the U.S., submit

copy of resident alien

card, employment authorization

card (valid through term of

entry) or any visa type card eligible for in- state tuition at

the time of attendance at Florida state institution.

Required documentation as stipulated on Florida Public

University application.

Resident alien card,

employment authorization

card, copy of all visa types

eligible for in-state tuition.

Copy of military orders (DD214 or DD2058). If

you are a dependent,

present proof of dependence (EX: Spouse of military person

supplies marriage

certificate and spouse’s

military I.D.; dependent

child of military person

supplies birth certificate). If you are a

resident alien, supply a copy

of your resident alien card.

Letter from Florida public

school verifying employment.

Copy of scholarship

papers.

Copy of Florida Prepaid

statement of account with applicant’s name on

statement.

Transcript from Florida Public

University showing proof of completion

of 12 consecutive months of

college coursework at

F.S.U. Panama Canal branch.

If you are a dependent, you

must present proof of

dependency: marriage

certificate, federal income

tax form, or birth certificate.

Letter of verification from police agency or correction

agency.

Please note: your situation may include more than one category. For example, a student who is classified as both a Dependent and a Resident Alien must supply documentation for both the Dependent and the Resident Alien categories.

* If you are classified as independent, complete and sign for yourself the Information for Residency and Classification form on the other side of this form. If you are classified as a dependent, have your parent or legal guardian complete and sign the IRC form. To determine whether you are classified as independent or dependent, please read the definitions of these terms that appear on the IRC form.

Ind Is 24 years old, married, has a dependant, in the armed forces, ward of the court, or enrolled in a graduate degree programDAll other persons who do not meet the requirements of Independent

. .

2 3 4 5 _ x A. y 6 7 __8 __9 __0 ___

2/088

Photographic/Film Consent and Release Form

I hereby give my consent to The Florida International University Board of Trustees ("FIU"): (a) to record my likeness and voice on any video, audio, photographic, digital, electronic or any other medium at any time during the course of my enrollment as a student at the Herbert Wertheim College of Medicine and to use my name in connection with these recordings; and

(b) to use, reproduce, exhibit or distribute these recordings in whole or in part in perpetuity in any and all media throughout the universe (including but not limited to print publications, video tapes, non-theatrical, home video, CD-ROM, internet and any other electronic or other medium presently in existence or invented in the future) for any purpose that FIU, and those acting pursuant to its authority, deem appropriate, including promotional, recruiting, advertising and any commercial or non-commercial use.

I hereby release FIU from and against any and all claims, demands, actions, causes of actions, suits, costs, expenses, liabilities, and damages whatsoever that I may hereafter have from liability for any violation of any personal or proprietary right I may have in connection with such use of my likeness, voice, or name in any medium, and expressly waive any rights to privacy I may have under the Family Educational Rights and Privacy Act ("FERPA") and/or §1002.22, Fla. Stat. I understand and agree that all such recordings, in whatever medium, shall remain the property of FIU.

I have read and fully understand the terms of this release.

Signature:_______________________________ Panther ID #:_______________________ Print Name: _____________________________ Date:_____________________________

Medical Student Handbook Student Consent Agreement

I acknowledge that I have been provided access to, read, and understand the Florida International University Herbert Wertheim College of Medicine (HWCOM) Medical Student Handbook, which sets forth policies and procedures and other important information regarding my obligations and rights as a medical student. By signing this statement, I agree to abide by all requirements and policies and procedures contained therein as may be amended from time to time. I understand that HWCOM will periodically update its policies and procedures. Florida International University and HWCOM reserve the right to change, rescind, or include additional policies and procedures in the HWCOM Medical Student Handbook. I understand that such changes and additions may occur without notice and that I will periodically check and review the online version of the HWCOM Medical Student Handbook throughout my enrollment at the medical school to obtain current information. I understand that the HWCOM Medical Student Handbook includes the obligation to comply with laws governing my activities as a medical student as a part of my obligation to meet professionalism standards established by HWCOM. These laws include strict obligations to maintain the confidentiality of student education records under the Family Education Rights and Privacy Act (FERPA) and patient information under the Health Insurance Portability and Accountability Act (HIPAA). The HWCOM Medical Student Handbook is available online at:

http://medicine.fiu.edu/handbook/

Signature:_______________________________ Panther ID #:_______________________

Print Name: _____________________________ Date:_____________________________

Office of Student Affairs

Matriculation and Retention Requirements Herbert Wertheim College of Medicine works directly with American DataBank to facilitate the process of

ensuring compliance with requirements pertaining to immunizations, medical history and examination

forms, health insurance documentation, criminal background checks, and drug testing.

Students must meet certain requirements to matriculate and to re-enroll annually. The requirements are

summarized in the table below:

Pre-matriculation Period 1 Period 2 Period 3 Period 4

Medical History and Physical Examination

X

Immunizations X

Flu Vaccine X X X X

Tuberculosis Screening X X X X

Health Insurance X X X X

Disability Insurance X X X X

Level 2 Criminal Background Check* X X X

10-Panel Drug Test* X X X

N-95 Respirator Mask Fit Test X X X

* Additional testing may be required by HWCOM or its clinical affiliates.

Additional requirements include Occupational Health and Safety Act (OSHA) and Health Insurance

Portability and Accountability Act (HIPAA) training as well as Basic Life Support (BLS) certification.

Once applicants accept an offer to enroll and matriculate at HWCOM, they must comply with all pre-

matriculation requirements. Students receive a notification from the HWCOM Office of Student Affairs with

a link to Orientation information on the college’s website; this information lists all pre-matriculation

requirements and forms. Students are notified of annual reenrollment requirements prior to promotion to

each subsequent period of study.

Most yearly compliance is conducted and reviewed as follows:

Entering Period 1 – May-July

Entering Period 2 – April-May

Entering Period 3 – January-April

Entering Period 4 – January-April

Additional communications about compliance and retention requirements are communicated, as

necessary, to students via their FIU email. Failure to comply with administrative requirements may result in

violations of professionalism.

Office of Financial Assistance

2017-2018 Tuition Payment Student Policy

HWCOM student accounts are maintained by the FIU Controller’s Office. All charges for the current academic year/term

will be posted in the student’s account, which can be viewed in MyFIU. The student is responsible for ensuring payment

is made or deferred by an accepted financial aid award by the designated deadline. The student must pay any balance

remaining after financial aid has been applied. Students will receive by email annual Tuition Payment Policies and will

be responsible to abide by tuition deadlines.

HWCOM students are not eligible for payment plans.

Tuition Payment

Students will be contacted by email, InnerCOM, and CanvasMED in the following manner regarding tuition payment:

30 days prior to tuition deadline notification that tuition has been applied to the student account

14 days prior reminder of tuition deadline

7 days prior reminder of tuition deadline

Day of reminder of tuition deadline and application of late fee

Late fees in the amount of $100 are applied when a balance is due after the tuition payment deadline. Prior term balances not paid and declined payments (returned checks, declined credit cards) are also subject to the $100 late fee.

Four weeks after the tuition payment deadline, nonpayment results in cancellation of current enrollment; the student is

blocked from all HWCOM courses and activities. Nonpayment of tuition and fee charges also may result in the student

being reported to a collections agency.

Tuition Payment Deadlines 2017-2018

Fall tuition and fees due August 7, 2017

Fall late fee applied August 8, 2017

Spring tuition and fees due December 11, 2017

Spring late fee applied December 12, 2017

Summer tuition and fees due April 9, 2018

Summer late fee applied April 10, 2018

Disbursement and Refunds

All financial aid funds are disbursed and applied to any existing charges on the student account. Any leftover money for

the semester is then sent to the student as a refund to cover cost of living expenses. Financial Aid refunds are sent by

direct deposit to the bank account designated by the student in MYFIU.

Fall disbursement July 28, 2017

Spring disbursement November 27, 2017

Summer disbursement March 30, 2018

I have read and understand the information contained in the above policy.

Signature:___________________________________ Panther ID #:_________________________________

Print Name: _________________________________ Date:_______________________________________