Downloadable Forms

All forms are Adobe PDF files. If you have trouble viewing the form you need, you may need to install the free Adobe Reader application, available here.

CONSENT FOR CARE OF MINOR
Students under 18 years old must have their parent/guardian(s) provide consent for medical care at the Student Health Center.

HEALTH HISTORY
To allow us to provide you with the best possible care, please complete the on-line Personal Health History and Immunizations forms. If you are under 18, please have your parent/guardian(s) complete the form.

INSURANCE CLAIM
If you are covered under UC SHIP and would like to request reimbursement for charges incurred outside the Student Health Center, send a completed claim form along with your itemized billing statements (remember to keep a copy for your records) to the appropriate address. A claim form is required each time you submit claims.

CRUZCARE ENROLLMENT AND CANCELLATION FORM
At any time during the year you can enroll in the CruzCare plan. Or, if you have enrolled in the plan and would like to cancel for the remainder of the year please complete the CruzCare Enrollment and Cancellation form and submit to the Insurance Office at the Student Health Center.

MEDICAL RECORDS RELEASE
We provide copies of medical records, partial or complete, when required for care. Records can only be released by, or to, the patient with a signed release form. If you are under 18, your parent/guardian must be the one to sign and complete this form. We require a 72-hour advance notice to provide time to review, copy and prepare the record(s) for mailing, faxing, or pick up. For more information click here.

WAIVER REVERSAL
If a student would like to enroll in the Student Health Insurance Plan after they have waived this coverage, they may do so only at the beginning of a new quarter by submitting a Waiver Reversal to the Student Insurance Office. This must be submitted by the posted waiver date.

INSURANCE ENROLLMENT FORMS
Individuals who fall under the following categories may enroll in the student insurance plans by completing the USHIP or GSHIP Insurance Enrollment Form (provided below). Enrollment terms, conditions, and costs are provided on the enrollment forms. For detailed plan information, please see insurance page.

  • Dependents of eligible undergraduate or graduate students
  • Part-time Graduate Students
  • Approved Leave Of Absence (LOA)
  • Summer Enrollment