Forms & Brochures

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Immunizations

New Students
Graduate Division Student Immunization Requirements
Professional Student Immunization Requirements

Current Students
TB Mask Fit
PPD Sign and Symptom Review Form
Immunization Consent Form

Insurance

UC SHIP 2020-2021
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
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

UC SHIP 2019-2020
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
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

Voluntary and Dependent Plan Enrollment

US 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.

If you are a Program Coordinator wishing to enroll a student in health insurance under “Filing Fee” status please email [email protected].

Voluntary UC SHIP Rate Sheet - Graduate Programs
Voluntary UC SHIP Rate Sheet - Professional Programs
Voluntary UC SHIP Rate Sheet - Professional Programs Summer 2021

Dependent Enrollment Rate Sheet for Registered Graduate Division Students
Dependent Enrollment Rate Sheet for Registered Professional School Program Students
Dependent Enrollment Rate Sheet for Registered Professional School Program Students Summer 2021
Dependent Enrollment Rate Sheet for Scholars and Researchers
Please click here for all qualifying event enrollments (marriage/divorce, loss of prior coverage, newborns, etc.). The form must be submitted within 31 days of your qualifying event date.

Scholars and Researchers Enrollment Form - Bridges Curriculum
Scholars and Researchers Enrollment Form - Graduate Division
Scholars and Researchers Enrollment Form - Professional School Programs

Waiver

Criteria Worksheet
Glossary of Medical Insurance Terminology

Travel

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

Privacy Notices

Consent to Medical Treatment and Privacy Notice – students only
HIPAA Notice of Privacy Practices – non-students only

Medical Records

Release of Health Information
Revocation of Authorization to Release Health Information

Public Health

Coronavirus Symptom Self-Monitoring Formkeywords: covid, covid-19, coronavirus, testing, sars, sars-cov-2
UCSF Continue to work/Return to work Guidelines For Personnel

Mental Health

Promoting Student Mental Health Faculty & Staff Handbook + Training Resources