Forms & Brochures

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Immunizations

New Students
Graduate Division Student Immunization Requirements 2017
Professional Student Immunization Requirements 2017

Current Students
TB Symptoms Review Form
Hep B Declination
TB Mask Fit
Immunization Consent Form

Insurance

UC SHIP 2016-2017
Cost of Care Handout
UC Student Health Insurance Plan (UC SHIP) Brochure
Student and Covered Dependent(s) Benefits Summary (English)
Student and Covered Dependent(s) Benefits Summary (Spanish)
Student and Covered Dependent(s) Benefits Summary (Mandarin)
UC SHIP Medical Benefits Booklet
Medical Claim Form
UC SHIP Member Reciprocity Claim Form

Prescription Claim Form
Prescription Insurance Summary
Approved Formulary Drug List
Formulary Help Document
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
Anthem Blue View Vision Claim Form

International Claim Form

UC SHIP 2015-2016
Insurance Benefit Chart
UC Student Health Insurance Plan (UC SHIP) Brochure *
Student Benefits Summary *
Dependent Benefits Summary *
UC SHIP Benefits Booklet *
Medical Claim Form

Prescription Insurance Summary
Dependent Prescription Insurance Summary
*
Catamaran Mobile App
Prescription Claim Form
Prescription Mail Order Form
Approved Formulary Drug List

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

Vision Insurance Summary
Vision Explanation of Coverage
Anthem Blue View Vision Claim Form

International Claim Form

* (Updated 3/24/16 with changes retroactive to 8/1/15 to satisfy "Minimal Essential Coverage" requirements by ACA)

Enrollment Forms
Voluntary UC SHIP Enrollment Form
Dependent Enrollment Form for Registered Graduate Division and School of Medicine Students
Dependent Enrollment Form for Registered Professional School Programs Students
Scholars and Researchers Enrollment Form - Bridges Curriculum
Scholars and Researchers Enrollment Form - Graduate Division and School of Medicine
Scholars and Researchers Enrollment Form - Professional School Programs
Scholars and Researchers Dependent Enrollment Form
Affidavit of Domestic Partners

Waiver
Criteria Worksheet
Glossary of Medical Insurance Terminology
Insurance Waiver Appeal Form
Insurance Waiver Reversal Form

Travel

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

 

HIPAA -- non-students only

HIPAA Privacy Practice
HIPAA Addendum

 

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