Forms

New/Incoming Student Forms

Internal Medicine

New Patient Questionnaire

Health Information Management Forms

Release of Health Information Form - for information going to or being obtained from a third party
Designation of Patient Spokesperson
Designation of Contact Information
Connecticut Advance Directives Information and Forms
Request for Amendment to Medical Record
Release of Health Information Form (Japanese)
Release of Health Information Form (Korean)
Release of Health Information Form (Mandarin)
Release of Health Information Form (Spanish)

Claims Forms

Pharmacy Claim Form - Electronically submit your claim for reimbursement of outside pharmacy expenses, you will need your member ID number and the Yale Health RxBIN#017449; or mail the paper Pharmacy Claim Form.
Supplemental Claim Form
COVID-19 At Home Test Claim Form

Student Forms

Pediatric Forms

Other Forms