Carnegie Mellon

Forms Utilized by Student Health

Anti-Malaria form

• Anti-Malarial form

Consent Forms

• Consent form: email
  Used to grant Student Health permission to communicate with you via email.
• Consent form: Release of Information
  Used to grant the Student Health Center permission to release medical information to organizations or individuals you specify.

Domestic Partnership forms:

• Domestic Partnership form
• Registration Instructions
• Termination form

Health History

• Health History form:
  Used to provide Student Health with your past health history information.

Emergency Contraception

Emergency Contraception Request form is available. Although the emergency contraception is to be taken by a woman, a male or female student may request the medication.

Request for a Prescription Medication Refill

Use This Form to Request a refill if:
* the prescription was written by a health care provider at the Student
Health Service and
* you have refills available"
Drop the form off at Student Health Services. Please allow 24 hours to
process the refill.

Housing and Dining Special Needs forms:

• Special Housing Needs form:
  for residential students with special housing needs.
• Special Dining Needs form:
  for dining plan contract holders with special dining needs.

Insurance forms:

Medical

• Forms related to the contracted Medical Insurance plans
• Waiver form:
  used to waive out of the university mandated insurance
• Medical Insurance Enrollment form:
  used to enroll in the medical insurance.
• Medical Insurance Enrollment Change form:
• Medical Insurance Enrollment Cancellation form:
  used to add or drop dependents after your initial enrollment.

Dental and Vision

• Form related to contracted Dental Insurance
• Form related to contracted Vision Insurance
• Dental/Vision Enrollment form
• Domestic Partnerships

  For those enrolling partners as part of a Domestic Partnership, you must complete the Carnegie Mellon Domestic Partnership form found above. In addition, if you are enrolling in the dental or vision plan, you must complete the Guardian Life Insurance Company's Declaration of Domestic Partnership form. When you return your completed enrollment form to Student Health, include copies of these two forms.