Forms &amp; 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

All Students
N95 Mask Fit Test Clearance
TB Sign and Symptom Review Form
Immunization Consent Form
Flu Declination Letter [UCOP-fillable]

Insurance

UC SHIP 2022-2023 (New documents in process of being updated)
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
UC SHIP Sydney Health Mobile App Flyer
Medical Claim Form
UC SHIP Member Reciprocity Claim Form
UC SHIP Refund Request Form

Prescription Claim Form
Prescription Drug Plan Booklet
Approved Formulary Drug List
Exclusion List
Prescription Mail Order Form

Delta Dental Benefits Booklet
Delta Dental Claim Form

Vision Insurance Summary
Vision Benefits Booklet
Vision Benefits Booklet (Chinese)
Vision Benefits Booklet (Spanish)
Anthem Blue View Vision Claim Form

International Claim Form

UC SHIP 2021-2022
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
UC SHIP Student Health Mobile App Flyer
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 Benefits Booklet
Delta Dental Benefits Booklet (Chinese)
Delta Dental Benefits Booklet (Spanish)
Delta Dental Claim Form

Vision Insurance Summary
Vision Benefits Booklet
Vision Benefits Booklet (Chinese)
Vision Benefits Booklet (Spanish)
Anthem Blue View Vision Claim Form

International Claim Form

Voluntary and Dependent Plan Enrollment

UC SHIP offers voluntary enrollment to students on a leave of absence, filing fee, or for one quarter after coverage ends post graduation. Dependent coverage is also available. To enroll in the voluntary plan or to enroll your dependent(s) open the corresponding rate sheet below and click on the "here" link.

Students enrolling in the voluntary plan will need to upload their approved "Leave of Absence" petition, "Filing Fee" petition, or a screenshot of their Student Portal "Degree Information" (found on "Study List & Grades" menu) for the continuation coverage when UC SHIP coverage ends (only for students who graduated). Students enrolling dependents will need to upload documentation that satisfies eligibility requirements.

Voluntary UC SHIP Rate Sheet - Graduate Programs
Voluntary UC SHIP Rate Sheet - Professional Programs

Dependent Enrollment Rate Sheet for Registered Graduate Division Students
Dependent Enrollment Rate Sheet for Registered Professional School Program Students
Dependent Enrollment Rate Sheet for Scholars and Researchers

If you have a qualifying life event (marriage/divorce, loss of prior coverage, newborns, etc.) please complete the online enrollment form. The form must be submitted within 31 days of the qualifying event date.
Qualifying Event Online Enrollment

Scholars and Researchers Enrollment Form - School of Medicine
Scholars and Researchers Enrollment Form - Graduate Division
Scholars and Researchers Enrollment Form - Professional School Programs