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id="content" class="column"> <div class="inside"> <a id="main-content"></a> <div class="tabs"></div> <div class="region region-content"> <div id="block-system-main" class="block block-system"> <div class="content"> <div id="node-151" class="node node-page slider-secondary clearfix" about="/insurance/forms-brochures" typeof="sioc:Item foaf:Document"> <span property="dc:title" content="Forms and Brochures" class="rdf-meta element-hidden"></span><span property="sioc:num_replies" content="0" datatype="xsd:integer" class="rdf-meta element-hidden"></span> <div class="content"> <div class="field field-name-field-body field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><p><span><em>To view and download these documents, you will need to have the latest version of <span><a href="http://get.adobe.com/reader/">Adobe Acrobat Reader</a>.</span></em></span></p> <h2 class="title" id="immunizations">Immunizations</h2> <p id="immunizationsNew"><em>New Students</em><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/Immunization%20Requirements%20-%20Graduate%20Students_0.pdf">Graduate Division Student Immunization Requirements</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/Immunization%20Requirements%20-%20Professional%20Students_2.pdf">Professional Student Immunization Requirements</a></p> <h2><a id="insurance" name="insurance"></a>Insurance</h2> <p><em>UC SHIP 2024-2025 (New documents in process of being updated)</em><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/UC%20SHIP%202024_2025%20Handout%20UCSF_FINAL.pdf">UC Student Health Insurance Plan (UC SHIP) Brochure</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/UC-SHIP-SBC-UC-San-Francisco-2023-24-updated-August-12023.pdf">Student and Covered Dependent(s) Benefits Summary (English)</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/UCSF-Anthem-Benefit-Book.pdf">UC SHIP Medical Benefits Booklet</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/Sydney%20Step%20by%20Step.pdf">UC SHIP Sydney Health Mobile App Flyer</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/Anthem%20medical%20claim%20form.pdf">Medical Claim Form</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/UCSHIP%20member%20reciprocity%20claim_form%202013.pdf">UC SHIP Member Reciprocity Claim Form</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/UC%20SHIP%20Refund%20Request%20Form.pdf">UC SHIP Refund Request Form</a></p> <h3><a id="rx" name="rx"></a>Prescription</h3> <p><a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/OptumRx_Prescription_Reimbursement_Claim_Form_July2020.pdf">Prescription Claim Form</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/UCSF-Prescription-Drug-Plan-Booklet-070723.pdf">Prescription Drug Plan Booklet</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/MRKPREMSTANDARD_%28BK1-RXB%29_ORx%20Premium%20Standard.pdf" target="_blank">Approved Formulary Drug List</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/WF13754923_ORX_Premium%20exclusion%20list_JUL24_v1_508.pdf" target="_blank">Exclusion List</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/ORX5633S-CTRX_160329_FORM_NRX0002_Kansas_FINAL.pdf">Prescription Mail Order Form</a></p> <h3><a id="dental" name="dental"></a>Dental</h3> <p><a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/UCSF-Delta-Dental-Benefit-Booklet-110923.pdf">Delta Dental Benefits Booklet</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/CLAIM%20FORM_PPO_FORM%202011.pdf">Delta Dental Claim Form</a></p> <h3><a id="vision" name="vision"></a>Vision</h3> <p><a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/UC_SHIP_Vision_Summary_2023-2024.pdf">Vision Insurance Summary</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/UCSHIP%20VisionBooklet%202023_2024.pdf">Vision Benefits Booklet</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/vision-claim-form.pdf">Anthem Blue View Vision Claim Form</a><br /> <br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/International-Claim-Form-US-fillable.pdf">International Claim Form</a></p> <p> </p> <p><em>UC SHIP 2023-2024</em><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/CostofCare_23_24_1.pdf">Cost of Care Handout</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/uc-ship-brchr-ucsf-23-r02%20080223.pdf">UC Student Health Insurance Plan (UC SHIP) Brochure</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/UC-SHIP-SBC-UC-San-Francisco-2023-24-updated-August-12023.pdf">Student and Covered Dependent(s) Benefits Summary (English)</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/7Francisco%20Benefit%20Book%202023-2024.pdf">UC SHIP Medical Benefits Booklet</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/Sydney%20Step%20by%20Step.pdf">UC SHIP Sydney Health Mobile App Flyer</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/Anthem%20medical%20claim%20form.pdf">Medical Claim Form</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/UCSHIP%20member%20reciprocity%20claim_form%202013.pdf">UC SHIP Member Reciprocity Claim Form</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/UC%20SHIP%20Refund%20Request%20Form.pdf">UC SHIP Refund Request Form</a></p> <h3><a id="rx" name="rx"></a>Prescription</h3> <p><a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/OptumRx_Prescription_Reimbursement_Claim_Form_July2020.pdf">Prescription Claim Form</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/UCSF-Prescription-Drug-Plan-Booklet-070723.pdf">Prescription Drug Plan Booklet</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/UCSHIP_Abridged_17690_v8_1%201%202024_508.pdf" target="_blank">Approved Formulary Drug List</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/WF13754923_ORX_Premium%20exclusion%20list_JUL24_v1_508.pdf" target="_blank">Exclusion List</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/ORX5633S-CTRX_160329_FORM_NRX0002_Kansas_FINAL.pdf">Prescription Mail Order Form</a></p> <h3><a id="dental" name="dental"></a>Dental</h3> <p><a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/UCSF-Delta-Dental-Benefit-Booklet-110923.pdf">Delta Dental Benefits Booklet</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/CLAIM%20FORM_PPO_FORM%202011.pdf">Delta Dental Claim Form</a></p> <h3><a id="vision" name="vision"></a>Vision</h3> <p><a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/UC_SHIP_Vision_Summary_2023-2024.pdf">Vision Insurance Summary</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/UCSHIP%20VisionBooklet%202023_2024.pdf">Vision Benefits Booklet</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/vision-claim-form.pdf">Anthem Blue View Vision Claim Form</a><br /> <br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/International-Claim-Form-US-fillable.pdf">International Claim Form</a></p> <p> </p> <h2 class="title" id="enrollmentForms"><a id="ucshipEnrollment" name="ucshipEnrollment"></a>Voluntary and Dependent Plan Enrollment</h2> <div style="padding: 15px; margin-bottom: 10px; background-color: rgb(239, 239, 239);"> <p style="margin-bottom: 0px;">UC SHIP offers voluntary enrollment to students on a leave of absence, filing fee, or for one quarter after coverage ends post graduation. Dependent coverage is also available. To enroll in the voluntary plan or to enroll your dependent(s) open the corresponding rate sheet below and click on the "here" link.<br /> <br /> Students enrolling in the voluntary plan will need to upload their approved "Leave of Absence" petition, "Filing Fee" petition, or a screenshot of their Student Portal "Degree Expected Term" (found in last section of the "Summary" page) for the continuation coverage (only for students who graduated). Students enrolling dependents will need to upload documentation that satisfies eligibility requirements.</p> </div> <p><a href="https://studenthealth.ucsf.edu/sites/g/files/tkssra9906/f/wysiwyg/24-25_UCSF_Grad%20Division_Vol_PC.pdf">Voluntary UC SHIP Rate Sheet - Graduate Programs</a><br /> <a href="https://studenthealth.ucsf.edu/sites/g/files/tkssra9906/f/wysiwyg/24-25_UCSF_Prof_Vol_PC.pdf">Voluntary UC SHIP Rate Sheet - Professional Programs</a></p> <p><a href="/sites/g/files/tkssra9906/f/wysiwyg/24-25_UCSF_Grad%20HWM_PC.pdf">Dependent Enrollment Rate Sheet for Registered Graduate Division Students</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/24-25_UCSF_Prof_HWM_PC.pdf">Dependent Enrollment Rate Sheet for Registered Professional School Program Students</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/24-25_UCSF_Scholar_HWM_PC.pdf">Dependent Enrollment Rate Sheet for Scholars and Researchers</a><br /> <br /> If you have a qualifying life event (marriage/divorce, loss of prior coverage, newborns, etc.) please complete the online enrollment form. The form must be submitted within 31 days of the qualifying event date.<br /> <a href="https://www3.academichealthplans.com/student/onlineEnrollment?sid=301&schoolYear=&promoCode=QEDEP">Qualifying Event Online Enrollment</a></p> <p><a href="/sites/g/files/tkssra9906/f/wysiwyg/SRHP10%20Application%202024-25.pdf">Scholars and Researchers Enrollment Form - School of Medicine</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/SRHP1%20Application%202024-25.pdf">Scholars and Researchers Enrollment Form - Graduate Division</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/SRHP2%20Application%202024-25.pdf">Scholars and Researchers Enrollment Form - Professional School Programs</a></p> <p> </p> <h2>Waiver</h2> <p><a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/2016%20GLOSSARY%20of%20Medical%20Insurance%20Terminology_0.pdf">Glossary of Medical Insurance Terminology</a></p> <h2 class="title" id="travel">Travel</h2> <p><a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/blueCard_worldWide_insurance_2020_2.pdf">Travel Insurance</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/International-Claim-Form-US-fillable.pdf">International Claim Form</a></p> <h2 class="title" id="privacyNotices">Privacy Notices</h2> <p><a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/CONSENT_TO_MEDICAL_TREATMENT_AND_PRIVACY_NOTICE-FINAL_3.16.20_2.pdf">Consent to Medical Treatment and Privacy Notice – students only</a><br /> <a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/UCSF_SHCS_HIPPA_NPP_Jan2018.pdf">HIPAA Notice of Privacy Practices – non-students only</a></p> <p></p> <h2 class="title" id="mentalHealth">Mental Health</h2> <p></p> <p><a href="/sites/g/files/tkssra9906/f/wysiwyg/pdfs/Promoting%20Student%20Mental%20Health_Faculty-Staff%20Handbook%20%2B%20Training%20Resources.pdf">Promoting Student Mental Health Faculty & Staff Handbook + Training Resources</a></p> </div></div></div> </div> </div> </div> </div> </div> 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href="/insurance/vision-plan">Vision Plan</a></li> </ul></div> </div> </div> </div> </div> </div> </div></div> <div id="footer"> <div class="section"> <div class="region region-footer"> <div id="block-block-16" class="block block-block"> <div class="content"> <p><strong>UCSF Student Mental Health and Wellbeing</strong></p> <div aria-label="Student Health and Counseling Contact Information Footer" class="wysiwyg_threecols layout--33-33-33" role="region"> <div class="wysiwyg_threecols--first bg--undefined bg--transparent"> <p><strong>Parnassus</strong><br /> 500 Parnassus Ave.,<br /> level P8, room 005<br /> San Francisco, CA 94143<br /> <b>Telephone:</b> (415) 476-1281<br /> <strong>email: </strong><a href="/cdn-cgi/l/email-protection#4a3927223d0a3f29392c642f2e3f"><span class="__cf_email__" data-cfemail="17647a7f60576274647139727362">[email protected]</span></a></p> <p> </p> </div> <div class="wysiwyg_threecols--second bg--undefined bg--transparent"> <p><strong>Mission Bay</strong><br /> 1675 Owens St.,<br /> Rutter Center, 3rd Floor, room 330<br /> San Francisco, CA 94158<br /> <strong>Telephone:</strong> (415) 476-1281<br /> <strong>email: </strong><a href="/cdn-cgi/l/email-protection#394a54514e794c5a4a5f175c5d4c"><span class="__cf_email__" data-cfemail="27544a4f50675244544109424352">[email protected]</span></a></p> <p> </p> </div> <div class="wysiwyg_threecols--third bg--undefined bg--transparent"> <p class="par-biggest">Key Resources</p> <p><a href="https://success.ucsf.edu/" target="_blank">Student Success Center</a></p> <p><a href="https://careadvocate.ucsf.edu/" target="_blank">CARE Advocate</a></p> <p><a href="https://sds.ucsf.edu/" target="_blank">Student Disability Services</a></p> <p><a href="https://diversity.ucsf.edu/" target="_blank">Office of Diversity and Outreach</a></p> <p><a href="https://studentmentalhealth.ucsf.edu/sexual-misconduct-reporting" target="_blank">Sexual Misconduct Reporting</a></p> </div> </div> <p>► <em><a 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