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Ž New
Student Requirement forms:
1.
Immunization Record Form
2.
Immunization Waiver Form
Ž First Time Visit Forms
- First
time Visit Form
- Medical History Form
Ž
Summer Health Insurace Application form
-
Summer Health Insurace Application form
Ž
Women's Health Form
- Women's Health Exams Form
Ž
Insurance and other forms:
1. Medical record
Release form: To release or obtain
a copy of your immunization records or any medical records, submitted to
us, please download this form and mail or fax it to us. We will mail or
fax your records within two days of receiving the request.
2.
Dependent application form for
Main campus Student: All students who want to enroll dependents
in their insurance plan need to fill out this form and mail it along with
dependent fees to the address specified on the top of the form.
3. Dependent
application form for Stuart campus Student: All students who want to enroll dependents in
their insurance plan need to fill out this form and mail it along with
dependent fees to the address specified on the top of the form.
4.
Prescription Drug Claim form: Students needing to submit a claim for a
prescription to the Insurance Company should fill out this form and mail
it along with the pharmacy receipt to the address on the form. Please
access the insurance tab for more information.
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