Forms & Brochures

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Immunizations

• New Students
• New Student Immunization Letter 2013-2014
• New Student Immunization Form 2013-2014
• Provider Release of Info
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• Current Students
• TB Symptoms Review Form
• Hep B Declination
• TB Mask Fit
• Immunization Consent Form
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Insurance

• UC SHIP 2012-2013
• Insurance Benefit Chart
• UC Student Health Insurance Plan (UC SHIP) Brochure
• Student Benefits Summary
• Dependent Benefits Chart
• Dependent Medical Insurance Summary
• Outpatient Treatment Report Form
• Medical Claim Form
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• Prescription Insurance Summary
• Dependent Prescription Insurance Summary
• Prescription Claim Form
• Approved Formulary Drug List
• Specialty Formulary
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• Delta Dental Insurance Summary
• Delta Dental Claim Form

Vision Insurance Summary
Anthem Blue View Vision Claim Form

International Claim Form

• Enrollment Forms
• Voluntary UC SHIP Enrollment Form
• Dependent Enrollment Form for Registered Students
• Scholars and Researchers Enrollment Form
• Scholars and Researchers Dependent Enrollment Form
• Affidavit of Domestic Partners

• Waiver
• Insurance Waiver Appeal Form
• Insurance Waiver Reversal Form
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Travel

• Travel Insurance
• Travel Screening Questionnaire
• Traveler's Diarrhea
• Malaria
• Trauma
• International Claim Form

HIPAA

• HIPAA Privacy Practice
• HIPAA Addendum
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Medical Records

• Health History Form - female
• Health History Form - male
• Release of Health Information

Mental Health

Assisting Students In Need
Caring for Yourself and Your Colleagues