Forms

Foreign Travel Forms

HIPAA Communication Preferences Authorization

HIPAA 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)

Minor Consent Form

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

Telehealth Consent Form (Fillable/signable PDF) - for remote counseling services 

UofL Sports Medicine Physical Form

How to File Claims

United Healthcare Claim Form

International Student Health Insurance Waiver Categories

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

GME Immunization Tracking Form (DOCX) - to submit with your immunization records

Instructions to Upload Out of State COVID Immunization Forms (DOCX)

N95 Decon Respirator Medical Questionnaire (use only for N95 Decon program)

IACUC Medical Surveillance Questionnaire

Respirator Medical Evaluation Questionnaire

BSL3-ABSL3 Medical Surveillance Forms

Workers Compensation Forms for Faculty and Staff of the university

Patient Drug Assistance Information

Implanon Patient Assistance Form

Mirena Patient Assistance Form

Paragard Patient Assistance Form

 UofL Anonymous Reporting Form