Forms and Guidelines

New Members

Welcome to Yale Health! Please review the below forms and guides for information about your health services.

Have a question? Reach out to our Member Liaison!
Doctor with female patient

New Patients

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.

Forms

Adult New Patient Questionnaire
Pediatric New Patient Questionnaire
Opting out of CONNIE (Connecticut's Health Information Exchange)

Guides

Member Guide to Yale Health
Member Coverage Booklet
Using MyChart
Member Guide to Yale Health
Notice of Privacy Practices
Privacy of Your Medical Record & Research

Students

Please review these forms and guides for information about your health services requirements and deadlines for submission.

Question about your coverage?

Contact your Student Health Care Navigator

Forms

New Student Health Requirements
Summer Session Student Forms
Information for Yale Parents
Student Waiver Submission
Student Allergy Forms
Student Enrollment/Change Application Form
Undergraduate Affiliate Coverage Form
Student Revoke Waiver Request Form
Yale Student Vaccine Medical Exemption Form

Guides

Student Handbook
Student Rates
Using MyChart
Meet Your Student Health Care Navigator
Notice of Privacy Practices
Privacy of Your Medical Record & Research

Pediatrics

Forms

Authorization to Transfer Medical Records to Yale Health
Pediatrics New Patient Questionnaire
School/Sports/Camp State Health Form
Sports Pre-Participation History Form
Preschool/Daycare State Health Form
Authorization for the Administration of Medicine by School Personnel

Guides

Information About Pediatric Vaccines
Medical Chaperone

Claims

You will need your member ID number and the Yale Health RxBin# to submit your claim for reimbursement of outside pharmacy expenses online. 

Forms

Pharmacy Claim Form (Paper)
Pharmacy Claim Form (Electronic)
Supplemental Claim Form
Retiree Major Medical Claim Form

Health Information Management

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.

Forms

Request Access to Protected Health Information Form
Designation of Contact Information
Connecticut Advance Directives Information and Forms
Request for Amendment to Medical Record
Student Mental Health & Counseling Records Requests
Release of Health Information Form (Spanish)
Release of Health Information Form (Mandarin)
Release of Health Information Form (Japanese)
Release of Health Information Form (Korean)
Designation of Patient Spokesperson (English)
Designation of Patient Spokesperson (Spanish)
Designation of Patient Spokesperson (Mandarin)
Designation of Patient Spokesperson (Japanese)
Designation of Patient Spokesperson (Korean)

Other Forms & Guides

Forms

Billed Associates Enrollment Form
Patient Registration – Fee for Service
Unpaid Post Doc Fellow Enrollment Form
School of Management EMBA Program 2024-25 Student Enrollment Application for Yale Health Hospitalization & Specialty Care Coverage (Affiliate/Self-Pay)
Notice of Privacy Practices
Insurance Information Update (COB) Form

Guides

Using MyChart
Unpaid Post-Doctoral Fellows
Ask Yale
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