Forms

General Patient Forms

 

Foreign Travel Forms

Healthcare Readiness Checklist

HIPPA Notice of Privacy Practices

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

Release of Psychotherapy Records Form - to request records be sent from Campus Health Services

UofL Sports Medicine Physical Form


Academic Health Plan / Insurance Forms

 

How to File Claims

United Healthcare Claim Form


International Students

 

International Student Health Insurance Waiver Categories


Health Sciences Center Immunization Forms

 

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

 

Medical Surveillance Questionnaire

Respirator Medical Evaluation Questionnaire

Workers Compensation Forms for Faculty and Staff of the university


Patient Drug Assistance

 

Patient Drug Assistance Information

Implanon Patient Assistance Form

Mirena Patient Assistance Form

Paragard Patient Assistance Form


Reporting Sexual Misconduct or Assault

 

UofL Anonymous Reporting Form