Forms and Guidelines

New Members

Thank you for choosing Yale Health as your healthcare home. Check out our new members page for more information about your transition to Yale Health. Many of the forms and guidelines for our members are listed below for your convenience.

New Member Information
Yale Health New Member Enrollment Info

New Patients

Welcome to Yale Health! 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

Welcome to Yale Health! Please review these forms and guides for information about your health services requirements and deadlines for submission.

Forms

New Student Health Requirements
Summer Session Student Forms
Early Start Student Forms
Information for Yale Parents
Student Waiver Submission
Student Allergy Forms
Student Enrollment/Change Application Form
Connecticut Medical Exemption Certificate for Required Immunizations

Guides

Student Handbook
Student Rates
Using MyChart
Member Guide to Yale Health
Notice of Privacy Practices
Privacy of Your Medical Record & Research

Pediatrics

Forms

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

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 Patient Spokesperson
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 (Japanese)
Release of Health Information Form (Korean)
Release of Health Information Form (Mandarin)
Release of Health Information Form (Spanish)

Other Forms & Guides

Forms

Notice of Privacy Practices
Insurance Information Update (COB) Form

Guides

Using MyChart
Unpaid Post-Doctoral Fellows