Quick Links to Forms and Information

Following are links to the most commonly used forms. If you have questions or concerns, please feel free to contact us by e-mail, or by phone (858) 534-3300.

Insurance Forms

Please note, the Health Fee Waiver application is not available here. The waiver application is only available on-line through the Health Fee Waiver Tool in the TritonLink Toolbox. Please click here for more information about the waiver.

Medical Records Forms

Authorization for Release of Health Information form - If you need your UCSD medical records sent to another health care provider, fax this form to our Medical Records Department at (858) 534-7545. If you have questions, call Medical Records at (858) 534-2139.

Nutrition Forms

Dietary Assessment form

Miscellaneous Forms

ELP Health History form (pg.1) and ELP Health History form (pg.2)
Consent for Medical Treatment of Minors - for any student under 18 years of age seeking health care. Have a parent/guardian sign it, and fax it to our Medical Records Department at (858) 534-7545. If you have questions, call Medical Records at (858) 534-2139.
Consent for Immunization of a Minor. Have a parent/guardian sign it, and fax it to our Medical Records Department at (858) 534-7545. If you have questions, call Medical Records at (858) 534-2139.
HIPAA Guidelines - Your rights and our obligations regarding the use and disclosure of your medical information in accordance with state and federal regulations (includes Q&A).
Acknowledgement of Privacy Practices form.
Patient Rights and Responsibilities

Optometry Forms

Optometry Patient History Questionnaire - Print this form, complete, and bring it to your Optometry visit. If you have questions, call the Optometry Department at (858) 534-2602.