Forms: Healthcare Related

Advance Directives

• Living Will, Health Care Surrogate Designation & Anatomical Donation

Allergy Injection Therapy

• Welcome to the Allergy Clinic

General

• Domestic Partnership Affidavit
• Health History Questionnaire
• Health Risk Profile
• Mandatory Immunization Health History Form
• Notice of Privacy Practices & Acknowledgement of Receipt Form

Insurance Verification

• ELECTRONIC: Online Insurance Verification Form
• PAPER: Insurance Verification Form

Nutrition Services

• Food Record
• Nutrition Questionnaire

Occupational Medicine

Find all forms required for your job duty here: UF Environmental Health and Safety (EH&S) Job Duty Listings and Occupational Medicine Program Forms. Please note: If the required forms are not complete, we cannot complete the health assessment, which in turn may delay the hiring process.

• Hepatitis A Vaccination Form – Law Enforcement
• Preplacement Physical Exam and Medical History – All on list except Animal Contact, Contact with Human Blood, Noise and Patient Contact
• Preplacement Screening Patient Contact Form – Patient Contact
• Preplacement Screening Patient Contact Form for Residents – Patient Contact for Residents
• TB Surveillance Form – Patient Contact and Patient Contact for Residents

Records/X-rays

• Release of Medical Records for General Purposes
  • In accordance with the Health Insurance Portability and Accountability Act (HIPAA), the SHCC may not release information about medical care for any student 18 or over without express permission from the patient. (By law, medical records for patients 17 and under are available to parents.)
  • This form may not be used to request future medical/immunization records. Current UF SHCC patients may use this form to request copies of past medical or immunization records or to allow a third party verbal access to current diagnoses/treatments for specific conditions for a designated period of time.
  • Should a patient 18 or over wish to release specific medical information to a third party, such as a parent or family member, they should inform their health care provider during or immediately after their visit. As each visit is treated individually, the patient must inform their health care provider of their wishes at each visit.
• Release of Medical Records for a Medical Withdrawal from UF Classes
• X-ray Copies Form

Women’s Health

• Health Risk Profile
• Women’s Health History Form