Forms
General Patient Forms
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Healthcare Readiness Checklist
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)
Patient Rights and Responsibilities
Personal Health, Medication & Immunization card
UofL Sports Medicine Physical Form
Academic Health Plans/Insurance Forms
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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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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
