Services & Departments Allergy Billing-Finance Care Coordination Claims Dermatology Employee Health Endoscopy Suite Health Promotion Inpatient Care Facility (ICF) Internal Medicine Lab Member Services Mental Health and Counseling Ob-Gyn Ophthalmology/Optometry Pediatrics Pharmacy/Prescriptions Physical Therapy Radiology Sports Medicine Student Health Education Student Medicine Surgical Specialties Travel Urgent Care

Forms - alpha order

• 19-25 Year Old Dependent Form

• 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

• Benefits Revision Form

• Child Health Record
• COBRA 18 Month Form
• Comment Card
• Claim Form

• Employee Enrollment/Change Form - Clerical & Technical, Service & Maintenance
• Employee Enrollment/Change Form - Faculty, Managerial & Professional

• Genetic Screening Form

• Health Assessment Record
• Health Information Release Form
• Health Information Request Form
• Health Professions Vaccination Record

• Instructions for Completing Pre-Entrance Health Forms
• Instructions for 1 hour Glucose tolerance test
• Instructions for 3 hour Glucose tolerance test
• Insurance Information Update Form (COB)
• Intercollegiate Athlete Medical Form

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

• New Student Health Checklist
• New Student Health Checklist (School of Nursing, School of Medicine & PA Program)
• NOPP Notice

• Pre entrance Health Form
• Prescription Plus Amendment

• Quick Guide to Yale University Health Services

• Retiree Major Medical Claim Form
• Revoke Waiver

• Student Allergy Medical Treatment Plan
• Student Enrollment/Change Application (for dependents and Affiliate plan)
• Student Premiums/Rates
• Student Travel Form

• Tax Insurance Summary Request Form
• Travel Form

• Ultrasound Instructions

• Vaccination Record for Incoming Students
• Varsity Athlete Letter for Incoming Students
• Varsity Athlete Medical History Questionnaire

• YHP Student Handbook