All forms are Adobe PDF files. If youhave trouble viewing the form you need, you may need to install the free Adobe Reader application, available here.
Know exactly which form you need? Here are quick links to all the forms described on this page:
- Consent for Care of Minor
- Medical Records Release
- CruzCare Enrollment/Cancellation
- Insurance Claim
- UC SHIP Waiver Reversal
- UC SHIP Brochure
- UC SHIP Voluntary Student/Dependent Enrollment Form (Undergrad)
- UC SHIP Voluntary Student/Dependent Enrollment Form (Grad)
- GSHIP Dental Evidence of Coverage
- GSHIP Vision Evidence of Coverage
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.
» Consent Form (PDF)
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.
All entering Frosh under 19 years old are required by the State of California to be immunized against Hepatitis B prior to their enrollment. Students needing Hepatitis B immunization should begin this three shot series right away with their local health care provider.
If you fall into this group, you will be sent information during the summer explaining this law and need to fill out the on-line Hepatitis B Status Statement to expedite the process of documenting compliance. Minimally, students must provide documentation they have received the first injection of the series before the first day of instruction. Immunization may be waived on principle of personal beliefs, but the form must still be completed and submitted by the required date. If this proof is not provided by the first day of instruction Fall Quarter, a student may be dropped from her/his classes.
»On-line Hepatitis B Immunization Status Statement
If you are covered under USHIP/GSHIP 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.
» Insurance Claim Form (PDF)
You may waive the Graduate Student Health Insurance Plan (GSHIP) if you have comparable insurance through another provider. Please take a moment to review your plan before making this decision. To decline GSHIP insurance, submit a completed waiver form along with proof of comparable insurance coverage by the appropriate deadline. Please note you may only add or drop GSHIP coverage at the beginning of each quarter. For more information and waiver deadlines, [CLICK HERE].
You may waive the Undergraduate Health Insurance Plan (UHIP) if you have comparable coverage through another provider. Please take a moment to review your plan before making this decision. To decline UHIP insurance, you must submit a completed waiver form along with proof of comparable insurance coverage by the appropriate deadline. Please note you may only add or drop UHIP coverage at the beginning of each quarter. For more information and waiver deadline, [CLICK HERE].
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.
» CruzCare Enrollment and Cancellation Form (PDF)
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].
»Medical Records Release (PDF)
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.
»Waiver Reversal (PDF)
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 refer to the USHIP Medical Brochure.
- Dependents of eligible undergraduate or graduate students
- Part-time Graduate Students
- Approved Leave Of Absence (LOA)
- Summer Enrollment
PRESCRIPTION DRUG REIMBURSEMENT FORM
» Prescription Drug Reimbursement Form (PDF)