Forms & Brochures

To view and download these documents, you will need to have the latest version of Adobe Acrobat Reader.

Immunizations

New Students
Graduate Division Student Immunization Requirements
Professional Student Immunization Requirements

Current Students
TB Mask Fit
Immunization Consent Form

Insurance

UC SHIP 2019-2020
Cost of Care Handout
UC SHIP Mobile App Download Instructions
UC Student Health Insurance Plan (UC SHIP) Brochure
Student and Covered Dependent(s) Benefits Summary (English)
UC SHIP Medical Benefit Booklet
Medical Claim Form
UC SHIP Member Reciprocity Claim Form

Prescription Claim Form
Prescription Insurance Summary
Approved Formulary Drug List
Exclusion List
Prescription Mail Order Form

Delta Dental Benefits Summary
Delta Dental Benefit Booklet
Delta Dental Claim Form

Vision Explanation of Coverage
Vision Explanation of Coverage (Spanish)
Vision Explanation of Coverage (Chinese)
Anthem Blue View Vision Claim Form

International Claim Form

UC SHIP 2018-2019
Cost of Care Handout
UC Student Health Insurance Plan (UC SHIP) Brochure
Student and Covered Dependent(s) Benefits Summary (English)
UC SHIP Medical Benefits Booklet
Transgender Benefits
Medical Claim Form
UC SHIP Member Reciprocity Claim Form
UC SHIP Refund Request Form

Prescription Claim Form
Prescription Insurance Summary ​
Approved Formulary Drug List
Exclusion List
Prescription Mail Order Form

Delta Dental Benefits Summary
Delta Dental Explanation of Coverage
Delta Dental Claim Form

Vision Insurance Summary
Vision Explanation of Coverage
Vision Explanation of Coverage (Spanish)
Anthem Blue View Vision Claim Form

International Claim Form

Enrollment Forms

Voluntary UC SHIP Enrollment Form - Graduate Programs
Voluntary UC SHIP Enrollment Form - Professional Programs (Summer 19 - Spring 20)
Voluntary UC SHIP Enrollment Form - Professional Programs (Summer 20)
Dependent Enrollment Form for Registered Graduate Division Students
Dependent Enrollment Form for Registered Professional School Programs Students (Summer 19 - Spring 20)
Dependent Enrollment Form for Registered Professional School Programs Students (Summer 20)
Scholars and Researchers Enrollment Form - School of Medicine
Scholars and Researchers Enrollment Form - Graduate Division
Scholars and Researchers Enrollment Form - Professional School Programs
Scholars and Researchers Dependent Enrollment Form

Waiver

Waiver Criteria
UC SHIP Non-Academic Condition of Enrollment
Glossary of Medical Insurance Terminology

Travel

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

HIPAA -- non-students only

HIPAA Privacy Practice

Medical Records

Release of Health Information
Revocation of Authorization to Release Health Information

Mental Health

Assisting Students In Distress
Assisting Peers In Distress
Caring for Yourself and Your Colleagues
Promoting Student Mental Health Faculty & Staff Handbook + Training Resources