Academic Year 2009 – 2010

Medical Forms

Student Health Service Health History Form

Authorization for Disclosure of Health Information (From Ohio University to another provider)

Authorization for Disclosure of Health Information (From another provider to Ohio University)

Application for Forgiveness

Insurance Information Request Form

Insurance Forms

United Healthcare Brochure 2009 - 2010

Insurance Waiver Form

Insurance Application Form (You are automatically enrolled, but if you waived the insurance, then you may re-apply using this form.)

Temporary Student Insurance Card

Optional Major Medical Enrollment Form

Student Medical Insurance Referral Form

Domestic Partner Affidavit

Domestic Dependent Enrollment Form

International Dependendent Enrollment Form

Insurance Enrollment Form for J-1 Scholars and English Language Program Students and their Dependents

Special Category Form for J-1 Visa students

Special Category Form for all other situation

Personal Representative Appointment Form (PAR)

Insurance Prescription Submission Form

Pharmacy Reimbursement Claim Form

United Health Care offers students individual dental coverage at a unique rate. Although this dental insurance is not affiliated with Ohio University, we have provided links to the necessary forms below. This is NOT an OU student insurance policy.

Dental Benefit Summary

Dental Enrollment Form

Academic Year 2008-2009

United Healthcare 2008-2009 Brochure

Insurance Application Form (previously waived the insurance and now you need to add)

International Monthly Dependent Form

Special Category Form for the following situations:

• Dissertation
• Thesis
• J-1 Visa
• Visiting Scholar

Special Category Form for the following situations:

• Alternative Quarter Break
• Co-op
• Internship
• Education Aboard
• Student Insurance Plan Dependent Enrollment

Domestic Students Form International Students Form

• Student Medical Insurance Referral Form

Prescription Reimbursement

• Student Health Center Pharmacy
• All other Pharmacies

Academic Year 2007-2008

• Student Medical Insurance Information Form (for students enrolled in the Ohio University insurance policy, to submit SHS charges to the insurance company)
• Student Medical Insurance Referral Form (for students enrolled in the Ohio University insurance policy, to submit all medical charges other than SHS to the insurance company)

Academic Year 2006-2007

• Student Medical Insurance Information Form (for students enrolled in the Ohio University insurance policy, to submit SHS charges to the insurance company)
• Student Medical Insurance Referral Form (for students enrolled in the Ohio University insurance policy, to submit all medical charges other than SHS to the insurance company)