Student Health Services

Quick Links to Forms and Information

Quick Links to Forms and Information

Following are links to the most commonly used forms. If you have questions or concerns, please feel free to contact us by e-mail, or by phone (858) 534-3300.

Nutrition Forms

Dietary Assessment form

Consent for Medical Treatment of Minors - for any student under 18 years of age seeking health care. Have a parent/guardian sign it, and fax it to our Medical Records Department at (858) 534-7545. If you have questions, call Medical Records at (858) 534-2139.

Consent for Immunization of a Minor. Have a parent/guardian sign it, and fax it to our Medical Records Department at (858) 534-7545. If you have questions, call Medical Records at (858) 534-2139.

HIPAA Guidelines - Your rights and our obligations regarding the use and disclosure of your medical information in accordance with state and federal regulations (includes Q&A).

Acknowledgement of Privacy Practices form.

Patient Rights and Responsibilities

Several forms relative to Hepatitis B requirements for new students.

Optometry Forms

Optometry Patient History Questionnaire - Print this form, complete, and bring it to your Optometry visit. If you have questions, call the Optometry Department at (858) 534-2602.

Request Medical Records - If you need your UCSD medical records sent to another health care provider, fax this form to our Medical Records Department at (858) 534-7545. If you have questions, call Medical Records at (858) 534-2139.

Insurance Forms

Insurance Claim form 2009-2010

USHIP Insurance Claim form 2010-2011

Waiver Cancellation form

Waiver Appeal Application form

Exception to Closed Enrollment Request