Forms Center

Important Forms

Resources Links
Privacy Notice
This document applies to how information and records regarding your health care at the UC Merced Student Health and Counseling & Psychological Services (SHS/CAPS) may be used and disclosed and how you can get access to this information.
Privacy Notice
Waiver Worksheet
This work sheet can help you gather needed insurance information BEFORE you start the online Waiver Form.
Waiver Worksheet
Appeal Of Waiver Denial
If you were denied on your waiver application, you may submit an Appeal within seven (7) calendar days to the Insurance Office. The form can be filled out online then printed and signed.
Waiver Denial Appeal Form
Cancel Insurance Waiver
If your health insurance coverage is terminated you are required to enroll in UC SHIP. Submit an enrollment form to the Insurance Office.
Cancel Waiver & Enroll in UCSHIP
Consent For Care Of Minor
Students under the age of 18 years old must have their parent/guardian(s) provide consent for general medical care.
Minor Consent Form
Immunizations
All undergraduate and graduate students are covered under UC Merced's Immunization Policy. UC Merced has adopted the recommendations of the American College Health Association and the U.S. Centers for Disease Control.
Enter your immunizations online at myhealth.ucmerced.edu and send a copy of your immunization card into the Health Center for verification.
Immunization Policy
Immunization Exemption Policy
The University of California allows for exemptions to immunization requirements based on a medical condition, please follow the link for more information.
Immunization Exemption Policy
Immunization Medical Exemption Request Form
If you require a medical exemption from the UC Immunization Policy, please submit a request.
Immunization Medical Exemption Request Form
Medical Records Release
Records can only be released by, or to, the patient with a signed consent form. If you are under 18, your parent/guardian must be the one to sign this form.
We require at least ten (10) days advance notice to provide time to review the request, copy and prepare the medical record(s) for mailing, faxing or pick-up.
Medical Records Release Form
Seasonal Flu Consent
Students, faculty and staff receiving a seasonal flu shot must complete this form prior to vaccination.
Flu Consent Form
Confidential Communication Request
A confidential communication request is a request that communications be sent to the patient rather than policy holder at an alternate address or through an alternate mode of communication such as email.
Confidential Communication Request Form
Authorization for Release of Financial Information
This authorization is for the release of financial and insurance related information only. Release of medical records requires completion of a separate authorization.
Authorization for Release of Financial InformationForm
Revocation Authorization for Release of Financial Information
Revocation of authorization for the release of financial and insurance related information only. Release of medical records requires completion of a separate authorization.
Revocation Authorization for Release of Financial Information Form
Graduate Voluntary Student & Dependent Enrollment Form
UC Merced voluntary graduate student health insurance plan enrollment form.
Graduate Voluntary Student & Dependent Enrollment Form
Graduate Dependent Enrollment Form
UC Merced graduate student health insurance plan enrollment form for dependents of registered students.
Graduate Dependent Enrollment Form
Undergraduate Voluntary Student & Dependent Enrollment Form
UC Merced voluntary undergraduate student health insurance plan enrollment form.
Undergraduate Voluntary Student & Dependent Enrollment Form
Undergraduate Dependent Enrollment Form
UC Merced undergraduate student health insurance plan enrollment form for dependents of registered students.
Undergraduate Dependent Enrollment Form

H. Rajender Reddy Health Center