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.

 

INSURANCE CLAIM FORMS:
For UC SHIP related forms please see the insurance page 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.

 

MEDICAL RECORDS RELEASE
We provide copies of medical records, partial or complete, when requested. 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. Please allow 15 days to process your request. Records will mailed faxed, or picked up, we DO NOT email records.

 

MCD BIOLOGY APPEALS

If your college asked you to submit a Verification of Health Condition Form, you can first read the instructions here, then download the form.

 

DECLINATION OF INFLUENZA VACCINATION

 

To submit the form, log into Health e-Messenger with your username and gold password. On the left sidebar, select New Message, click on Medical Records Form Submission. Scan the form, then attach it to your message. Click Send. You can also fax or mail the form to us.