Departments & Services Allergy Athletic Medicine Billing-Finance Cardiology Care Coordination Claims Dermatology Employee Health Endocrinology Endoscopy Suite Gastroenterology Hematology/Oncology Immunizations Inpatient Care Facility (ICF) Internal Medicine Lab Member Services Mental Health and Counseling Neurology Nutrition Ob-Gyn Ophthalmology/Optometry Pediatrics Pharmacy/Prescriptions Physical Therapy Radiology Referral Coordination Student Health Education Students Surgical Specialties Travel Urgent Care

Forms - Alphabetical order

• Accounting for Disclosures of PHI form
• Acknowledgement Form Receipt of NOPP
• Address Change Form
• Advance Directives Form
• Authorization for Medical Care and Treatment for Minors
• Authorization for the Administration of Medicine by School Personnel

• Benefits Revision Form

• Child Health Record
• Comment Card
• Claim Form

• Early Childhood Health Assessment Record
• Employee Enrollment/Change Form - Clerical & Technical, Service & Maintenance
• Employee Enrollment/Change Form - Faculty, Managerial & Professional

• Genetic Screening Form

• Health Assessment Record - CT Department of Education
• Health Information Release Form
• Health Information Request Form

• Instructions for 1 hour Glucose tolerance test
• Instructions for 3 hour Glucose tolerance test
• Insurance Information Update Form (COB)

• Mail Order Form
• Medical Records Release Form
• Medical Records Request Form
• Mental Health & Counseling Records Release Form

• NOPP Notice

• Pediatric Initial History Questionnaire
• Prescription Plus Amendment

• Retiree Major Medical Claim Form
• Revoke Waiver

• Sports Participation Health Record

• Tax Insurance Summary Request Form
• Travel Form

• Ultrasound Instructions

• Yale Health Plan Initital History Questionnaire
• Youth Camp Health Exam/Record