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1440px)" type="image/jpeg" width="900" height="486"/> <img loading="eager" class="main_menu" src="/sites/default/files/styles/main_menu_1440/public/2024-04/23-023_YaleHealth_484.jpg?h=deaec4b9&itok=cTW4Y7mB" width="900" height="486" alt="children and parent in waiting area" /> </picture> </figure> </div> </div> </div> </details> </li> <li class="menu__item menu__item--active"> <a href="/forms-and-guidelines" aria-current="page" data-drupal-link-system-path="node/911" class="is-active">Forms & Guidelines</a> </li> </ul> </nav> </div> <div class="site-header__tools"> <a href="/search" aria-label="Yale Health search page"> <i class="fal fa-search"></i><span class="visually-hidden">Search</span> </a> <button class="menu-toggle" data-js="menu-toggle" aria-controls="block-main" aria-expanded="false"> <span></span> <span></span> <span></span> </button> </div> </div> </header> <main id="site-main" class="site-main"> <div class="site-main__system"> <div class="region-system"> <div data-drupal-messages-fallback class="hidden"></div> </div> </div> <div class="region-content"> <div id="block-yale-health-content"> <article class="node node--page node--full node--no-aside" data-js="node-page"> <header class="node__header" data-js="node-header"> <h1 class="node__heading"> Forms and Guidelines </h1> </header> <div class="node__content"> <div class="node__sections"> <div class="layout layout--one-column"> <div class="layout__content"> <div class="layout__regions"> <div class="layout__region layout__region--content"> <div class="layout__region-item"> <div class="paragraph paragraph--callout-block paragraph--default paragraph--image-position-right" data-js="callout-block"> <div class="paragraph__content"> <div class="paragraph__title"> Yale Students </div> <div class="paragraph__body"> <div class="ck-content"> <p><strong>Welcome to Yale Health!</strong> Please review these forms and guides for information about your health services requirements and deadlines for submission.</p></div> </div> <div class="paragraph__cta-link"> <a href="/new-student-health-requirements">New Student Health Requirements</a> </div> </div> <div class="paragraph__image"> <figure class="media media--image media--callout-portrait"> <picture> <source srcset="/sites/default/files/styles/callout_portrait_768/public/2023-07/Yale%20Health%20Website-046_0.webp?h=2fbceb31&itok=bdUNNUCL 1x, /sites/default/files/styles/callout_portrait_2x_768/public/2023-07/Yale%20Health%20Website-046_0.webp?h=2fbceb31&itok=ezIe-Bx7 2x" media="all and (min-width: 768px)" type="image/webp" width="576" height="700"/> <source srcset="/sites/default/files/styles/callout_portrait/public/2023-07/Yale%20Health%20Website-046_0.webp?h=2fbceb31&itok=btuIWDdq 1x, /sites/default/files/styles/callout_portrait_2x/public/2023-07/Yale%20Health%20Website-046_0.webp?h=2fbceb31&itok=Rx8I-RmH 2x" type="image/webp" width="349" height="424"/> <source srcset="/sites/default/files/styles/callout_portrait_768/public/2023-07/Yale%20Health%20Website-046_0.jpg?h=2fbceb31&itok=bdUNNUCL 1x, /sites/default/files/styles/callout_portrait_2x_768/public/2023-07/Yale%20Health%20Website-046_0.jpg?h=2fbceb31&itok=ezIe-Bx7 2x" media="all and (min-width: 768px)" type="image/jpeg" width="576" height="700"/> <source srcset="/sites/default/files/styles/callout_portrait/public/2023-07/Yale%20Health%20Website-046_0.jpg?h=2fbceb31&itok=btuIWDdq 1x, /sites/default/files/styles/callout_portrait_2x/public/2023-07/Yale%20Health%20Website-046_0.jpg?h=2fbceb31&itok=Rx8I-RmH 2x" type="image/jpeg" width="349" height="424"/> <img loading="eager" class="callout_portrait" src="/sites/default/files/styles/callout_portrait/public/2023-07/Yale%20Health%20Website-046_0.jpg?h=2fbceb31&itok=btuIWDdq" width="349" height="424" alt="Student health provider and student" /> </picture> </figure> </div> </div> </div> </div> </div> </div> </div> <section class="layout--33-33-33 layout--divider layout--has-header layout layout--three-column" aria-labelledby="heading-layout-1478"> <div class="layout__content"> <div class="layout__header"> <header class="advanced-header-field advanced-header-field--heading-tag-h2"> <h2 id="heading-layout-1478" class="advanced-header-field__heading"> New Patients </h2> </header> </div> <div class="layout__regions"> <div class="layout__region layout__region--first"> <div class="layout__region-item"> <div class="paragraph paragraph--html-content paragraph--default" data-js="html-content"> <div class="paragraph__body"> <div class="ck-content"> <p>Your care as a Yale Health member begins with your primary care provider (PCP) at Yale Health in Internal Medicine, Obstetrics and Gynecology, or Pediatrics.</p></div> </div> </div> </div> </div> <div class="layout__region layout__region--second"> <div class="layout__region-item"> <div class="paragraph paragraph--link-list paragraph--default" data-js="link-list"> <header class="advanced-header-field advanced-header-field--heading-tag-h3"> <h3 id="heading-link_list-1480" class="advanced-header-field__heading"> Forms </h3> </header> <div class="paragraph__links"> <div class="paragraph__link"><a href="/resource/new-patient-questionnaire">Adult New Patient Questionnaire</a></div> <div class="paragraph__link"><a href="/resource/pediatrics-new-patient-questionnaire">Pediatric New Patient Questionnaire</a></div> <div class="paragraph__link"><a href="https://hipaa.yale.edu/connie-connecticuts-health-information-exchange">Opting out of CONNIE (Connecticut's Health Information Exchange)</a></div> </div> </div> </div> </div> <div class="layout__region layout__region--third"> <div class="layout__region-item"> <div class="paragraph paragraph--link-list paragraph--default" data-js="link-list"> <header class="advanced-header-field advanced-header-field--heading-tag-h3"> <h3 id="heading-link_list-1481" class="advanced-header-field__heading"> Guides </h3> </header> <div class="paragraph__links"> <div class="paragraph__link"><a href="/resource/member-guide-yale-health">Member Guide to Yale Health</a></div> <div class="paragraph__link"><a href="/resource/employee-member-coverage-booklet-2023">Member Coverage Booklet</a></div> <div class="paragraph__link"><a href="/using-mychart">Using MyChart</a></div> <div class="paragraph__link"><a href="/resource/member-guide-yale-health">Member Guide to Yale Health</a></div> <div class="paragraph__link"><a href="/resource/notice-privacy-practices-0">Notice of Privacy Practices</a></div> <div class="paragraph__link"><a href="/topic/privacy-your-medical-record-research">Privacy of Your Medical Record & Research</a></div> </div> </div> </div> </div> </div> </div> </section> <section class="layout--33-33-33 layout--divider layout--has-header layout layout--three-column" aria-labelledby="heading-layout-1491"> <div class="layout__content"> <div class="layout__header"> <header class="advanced-header-field advanced-header-field--heading-tag-h2"> <h2 id="heading-layout-1491" class="advanced-header-field__heading"> Students </h2> </header> </div> <div class="layout__regions"> <div class="layout__region layout__region--first"> <div class="layout__region-item"> <div class="paragraph paragraph--html-content paragraph--default" data-js="html-content"> <div class="paragraph__body"> <div class="ck-content"> <p>Please review these forms and guides for information about your health services requirements and deadlines for submission.</p><p><em>Question about your coverage?</em></p></div> </div> </div> </div> <div class="layout__region-item"> <div class="paragraph paragraph--cta-link paragraph--default paragraph--cta-link-with-arrow" data-js="cta-link"> <a href="/student-health-care-navigator">Contact your Student Health Care Navigator</a> </div> </div> </div> <div class="layout__region layout__region--second"> <div class="layout__region-item"> <div class="paragraph paragraph--link-list paragraph--default" data-js="link-list"> <header class="advanced-header-field advanced-header-field--heading-tag-h3"> <h3 id="heading-link_list-1493" class="advanced-header-field__heading"> Forms </h3> </header> <div class="paragraph__links"> <div class="paragraph__link"><a href="https://yalehealth.yale.edu/new-student-health-requirements">New Student Health Requirements</a></div> <div class="paragraph__link"><a href="/topic/summer-session-student-forms">Summer Session Student Forms</a></div> <div class="paragraph__link"><a href="/topic/information-yale-parents">Information for Yale Parents</a></div> <div class="paragraph__link"><a href="/resource/student-waiver-submission">Student Waiver Submission</a></div> <div class="paragraph__link"><a href="/resource/student-allergy-forms">Student Allergy Forms</a></div> <div class="paragraph__link"><a href="/resource/student-enrollmentchange-application-form">Student Enrollment/Change Application Form</a></div> <div class="paragraph__link"><a href="/resource/undergraduate-affiliate-coverage-form">Undergraduate Affiliate Coverage Form</a></div> <div class="paragraph__link"><a href="/resource/student-revoke-waiver-form">Student Revoke Waiver Request Form</a></div> <div class="paragraph__link"><a href="/resource/yale-student-vaccine-medical-exemption-form">Yale Student Vaccine Medical Exemption Form</a></div> </div> </div> </div> </div> <div class="layout__region layout__region--third"> <div class="layout__region-item"> <div class="paragraph paragraph--link-list paragraph--default" data-js="link-list"> <header class="advanced-header-field advanced-header-field--heading-tag-h3"> <h3 id="heading-link_list-1494" class="advanced-header-field__heading"> Guides </h3> </header> <div class="paragraph__links"> <div class="paragraph__link"><a href="/resource/student-guide-yale-health-0">Student Handbook</a></div> <div class="paragraph__link"><a href="/topic/student-rates-2024-2025">Student Rates</a></div> <div class="paragraph__link"><a href="/using-mychart">Using MyChart</a></div> <div class="paragraph__link"><a href="/resource/meet-your-student-health-care-navigator">Meet Your Student Health Care Navigator</a></div> <div class="paragraph__link"><a href="/resource/notice-privacy-practices-0">Notice of Privacy Practices</a></div> <div class="paragraph__link"><a href="/topic/privacy-your-medical-record-research">Privacy of Your Medical Record & Research</a></div> </div> </div> </div> </div> </div> </div> </section> <section class="layout--33-33-33 layout--divider layout--has-header layout layout--three-column" aria-labelledby="heading-layout-1495"> <div class="layout__content"> <div class="layout__header"> <header class="advanced-header-field advanced-header-field--heading-tag-h2"> <h2 id="heading-layout-1495" class="advanced-header-field__heading"> Pediatrics </h2> </header> </div> <div class="layout__regions"> <div class="layout__region layout__region--first"> </div> <div class="layout__region layout__region--second"> <div class="layout__region-item"> <div class="paragraph paragraph--link-list paragraph--default" data-js="link-list"> <header class="advanced-header-field advanced-header-field--heading-tag-h3"> <h3 id="heading-link_list-1496" class="advanced-header-field__heading"> Forms </h3> </header> <div class="paragraph__links"> <div class="paragraph__link"><a href="/resource/authorization-transfer-medical-records-yale-health">Authorization to Transfer Medical Records to Yale Health</a></div> <div class="paragraph__link"><a href="/resource/pediatrics-new-patient-questionnaire">Pediatrics New Patient Questionnaire</a></div> <div class="paragraph__link"><a href="/resource/schoolsportscamp-state-health-form">School/Sports/Camp State Health Form</a></div> <div class="paragraph__link"><a href="/resource/sports-pre-participation-history-form">Sports Pre-Participation History Form</a></div> <div class="paragraph__link"><a href="/resource/preschooldaycare-state-health-form">Preschool/Daycare State Health Form</a></div> <div class="paragraph__link"><a href="/resource/authorization-administration-medicine-school-personnel">Authorization for the Administration of Medicine by School Personnel</a></div> </div> </div> </div> </div> <div class="layout__region layout__region--third"> <div class="layout__region-item"> <div class="paragraph paragraph--link-list paragraph--default" data-js="link-list"> <header class="advanced-header-field advanced-header-field--heading-tag-h3"> <h3 id="heading-link_list-1878" class="advanced-header-field__heading"> Guides </h3> </header> <div class="paragraph__links"> <div class="paragraph__link"><a href="/topic/pediatric-vaccines">Information About Pediatric Vaccines</a></div> <div class="paragraph__link"><a href="/topic/medical-chaperones-sensitive-examinations-treatments-and-procedures">Medical Chaperone</a></div> </div> </div> </div> </div> </div> </div> </section> <section class="layout--33-33-33 layout--divider layout--has-header layout layout--three-column" aria-labelledby="heading-layout-1483"> <div class="layout__content"> <div class="layout__header"> <header class="advanced-header-field advanced-header-field--heading-tag-h2"> <h2 id="heading-layout-1483" class="advanced-header-field__heading"> Claims </h2> </header> </div> <div class="layout__regions"> <div class="layout__region layout__region--first"> <div class="layout__region-item"> <div class="paragraph paragraph--html-content paragraph--default" data-js="html-content"> <div class="paragraph__body"> <div class="ck-content"> <p>You will need your member ID number and the Yale Health RxBin# to submit your claim for reimbursement of outside pharmacy expenses online. </p></div> </div> </div> </div> </div> <div class="layout__region layout__region--second"> <div class="layout__region-item"> <div class="paragraph paragraph--link-list paragraph--default" data-js="link-list"> <header class="advanced-header-field advanced-header-field--heading-tag-h3"> <h3 id="heading-link_list-1486" class="advanced-header-field__heading"> Forms </h3> </header> <div class="paragraph__links"> <div class="paragraph__link"><a href="/resource/pharmacy-claim-form">Pharmacy Claim Form (Paper)</a></div> <div class="paragraph__link"><a href="https://web.primetherapeutics.com/member/login/">Pharmacy Claim Form (Electronic)</a></div> <div class="paragraph__link"><a href="/resource/supplemental-claim-form-0">Supplemental Claim Form</a></div> <div class="paragraph__link"><a href="/resource/retiree-major-medical-claim-form">Retiree Major Medical Claim Form</a></div> </div> </div> </div> </div> <div class="layout__region layout__region--third"> </div> </div> </div> </section> <section class="layout--33-33-33 layout--divider layout--has-header layout layout--three-column" aria-labelledby="heading-layout-1487"> <div class="layout__content"> <div class="layout__header"> <header class="advanced-header-field advanced-header-field--heading-tag-h2"> <h2 id="heading-layout-1487" class="advanced-header-field__heading"> Health Information Management </h2> </header> </div> <div class="layout__regions"> <div class="layout__region layout__region--first"> <div class="layout__region-item"> <div class="paragraph paragraph--html-content paragraph--default" data-js="html-content"> <div class="paragraph__body"> <div class="ck-content"> <p>Representatives are available to answer questions regarding your release of information for members and authorized third party requesters. They can also assist with the completion of the Designation of Patient Spokesperson form, the Designation of Contact Information form and to answer any questions.</p></div> </div> </div> </div> </div> <div class="layout__region layout__region--second"> <div class="layout__region-item"> <div class="paragraph paragraph--link-list paragraph--default" data-js="link-list"> <header class="advanced-header-field advanced-header-field--heading-tag-h3"> <h3 id="heading-link_list-1490" class="advanced-header-field__heading"> Forms </h3> </header> <div class="paragraph__links"> <div class="paragraph__link"><a href="/resource/request-access-protected-health-information-form">Request Access to Protected Health Information Form</a></div> <div class="paragraph__link"><a href="/resource/designation-patient-spokesperson">Designation of Patient Spokesperson</a></div> <div class="paragraph__link"><a href="/resource/designation-contact-information">Designation of Contact Information</a></div> <div class="paragraph__link"><a href="/resource/connecticut-advance-directives-information-starter-kit">Connecticut Advance Directives Information and Forms</a></div> <div class="paragraph__link"><a href="/resource/request-amendment-medical-record">Request for Amendment to Medical Record</a></div> <div class="paragraph__link"><a href="/topic/student-mental-health-counseling-records-requests">Student Mental Health & Counseling Records Requests</a></div> <div class="paragraph__link"><a href="/resource/release-health-information-form-japanese">Release of Health Information Form (Japanese)</a></div> <div class="paragraph__link"><a href="/resource/release-health-information-form-korean">Release of Health Information Form (Korean)</a></div> <div class="paragraph__link"><a href="/resource/release-health-information-form-mandarin">Release of Health Information Form (Mandarin)</a></div> <div class="paragraph__link"><a href="/resource/release-health-information-form-spanish">Release of Health Information Form (Spanish)</a></div> </div> </div> </div> </div> <div class="layout__region layout__region--third"> </div> </div> </div> </section> <section class="layout--33-33-33 layout--divider layout--has-header layout layout--three-column" aria-labelledby="heading-layout-1498"> <div class="layout__content"> <div class="layout__header"> <header class="advanced-header-field advanced-header-field--heading-tag-h2"> <h2 id="heading-layout-1498" class="advanced-header-field__heading"> Other Forms & Guides </h2> </header> </div> <div class="layout__regions"> <div class="layout__region layout__region--first"> </div> <div class="layout__region layout__region--second"> <div class="layout__region-item"> <div class="paragraph paragraph--link-list paragraph--default" data-js="link-list"> <header class="advanced-header-field advanced-header-field--heading-tag-h3"> <h3 id="heading-link_list-1499" class="advanced-header-field__heading"> Forms </h3> </header> <div class="paragraph__links"> <div class="paragraph__link"><a href="/resource/billed-associates-associate-enrollment-form">Billed Associates Enrollment Form</a></div> <div class="paragraph__link"><a href="/resource/patient-registration-fee-service">Patient Registration – Fee for Service</a></div> <div class="paragraph__link"><a href="/resource/unpaid-post-doc-associate-enrollment-form">Unpaid Post Doc Fellow Enrollment Form </a></div> <div class="paragraph__link"><a href="/resource/school-management-emba-program-2024-25-student-enrollment-application-yale-health">School of Management EMBA Program 2024-25 Student Enrollment Application for Yale Health Hospitalization/Specialty Care Coverage (Affiliate/Self-Pay)</a></div> <div class="paragraph__link"><a href="/resource/notice-privacy-practices-0">Notice of Privacy Practices</a></div> <div class="paragraph__link"><a href="/resource/insurance-information-update-cob-form">Insurance Information Update (COB) Form</a></div> </div> </div> </div> </div> <div class="layout__region layout__region--third"> <div class="layout__region-item"> <div class="paragraph paragraph--link-list paragraph--default" data-js="link-list"> <header class="advanced-header-field advanced-header-field--heading-tag-h3"> <h3 id="heading-link_list-1500" class="advanced-header-field__heading"> Guides </h3> </header> <div class="paragraph__links"> <div class="paragraph__link"><a href="/using-mychart">Using MyChart</a></div> <div class="paragraph__link"><a href="/resource/unpaid-post-doctoral-fellows">Unpaid Post-Doctoral Fellows</a></div> </div> </div> </div> </div> </div> </div> </section> </div> </div> </article> </div> </div> </main> <footer class="site-footer"> <div class="site-footer__content"> <div class="site-footer__branding"> <div class="branding-block" data-js="branding-block"> <a href="/" title="Home" aria-label="Go to homepage" rel="home" > <?xml version="1.0" encoding="UTF-8"?> <svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 581.8 86.9"> <path 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