Forms

General Patient Forms

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Foreign Travel Forms

Healthcare Readiness Checklist

HIPPA Notice of Privacy Acts

Medical Records Request  -- to request records from Campus Health Services

Medical Records Request -- to request records to be sent to Campus Health Services (HSC)

Medical Records Request -- to request records to be sent to Campus Health Services (Cardinal Station)

New Patient Forms

Patient Rights and Responsibilities

Personal Health, Medication & Immunization card

UofL Sports Medicine Physical Form

Academic Health Plans/Insurance Forms

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How to File Claims

United Healthcare Claim Form

International Students

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International Student Health Insurance Waiver Categories

Health Sciences Center Immunization Forms

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HSC Student Immunization Tracking Form ---to submit with your immunization records

HSC Housestaff Immunization Tracking Form--to submit with your immunization records

Employee Health-Related Forms

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Medical Clearance Form

Respirator Fit Testing Questionnaire

Patient Drug Assistance Information

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Most patient assistance programs use some multiple of the proverty guidelines (typically 200% of poverty level) which is based on your household's total annual income and number of people in the house hold.  You should be prepared to back up your income levels with tax returns or similar documents.  Most assistance programs will determine this for you but it is helpful to know if you are even close to qualifying. 

Federal Poverty Level Calculator

Federal Poverty Guidelines

General Prescription Assistance Programs

http://www.pparx.org/ --- enter a one or more drug names and search multiple drug companies to find correct form(s) and completes form online for mailing or faxing.

http://www.rxassist.org/ --- search for prgram for a specific drug and then directs you to the correct site to find the appropriate forms. 

http://www.needymeds.org/ --- list of patient assistance programs by company and drug

Specific Programs

Implanon Patient Assistance Form

Mirena Patient Assistance Form

Paragard Patient Assistance Form