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Many of the forms we refer to throughout the web site are available here in the Adobe Acrobat page description file format (PDF).
To view and/or print these forms, you'll need Adobe Acrobat Reader, which you can download from MIT Information Services.
Affadavit
of Spousal Equivalent Partnership
For students who would like to enroll a spousal equivalent
partner in the MIT Student Health Plan or MIT Affiliate
Health Plan.
Blue
Cross Claim Form (2008 Mental health)
This form should be used for services received from a non-network
mental health provider. Members should request
their provider submit a claim on their behalf. If the provider
refuses, use this form along with an itemized bill.
Claim Form (Medical/Prescription
drug)
For prescription appliance, and prescription drug claims
for the MIT Student Extended Insurance Plan and the
MIT Affiliate Extended Insurance Plan. Claims that you
file yourself must be received by the MIT Health Plan or
Blue Cross Blue Shield within one year of the date of service.
This form should be used by Traditional and Flexible MIT
Health Plan members for prescription drugs and acupuncture
purchased in 2007.
Enrollment
Form (2007-2008)
For students who would like to enroll family members in
the MIT Student Health Plan, and for special students taking
at least one course but fewer than 27 units who would
like to enroll in the MIT Student Health Plan.
Medical
Report Form (2008-2009)
This form is for Summer 2008, Fall 2008 and Spring 2009 students.
Please check out the FAQ if
you have any questions.
Medical
Report Form (2007-2008)
This form is for Spring 2008 students. Please check out the FAQ if
you have any questions.
Medical
Record Release Form
For authorizing release of your records from MIT Medical
to another health care provider.
Patient Health
History Forms
Health history form for adult patients scheduled for a physical exam.
Pediatrics
History Forms
Health history form for new pediatric patients.
Personal Physician Form
For MIT students, affiliates, and Traditional and Flexible
health plan members who need a personal physician.
Pharmacy
Home Delivery Form
For home delivery of prescriptions within the United States.
Request
for Amendment of Protected Health Information
To amend your medical record.
ValueOptions
Claim Form (external website)
For 2007 services provided by an out-of-network provider, all reimbursement
claims require the filing of a CMS 1500 form or ValueOptions claim form, both
of which are available for download on the ValueOptions
website. Please read our ValueOptions FAQ if
you have any questions about filing a claim.
Waiver
Request (MIT certificate required)
To request waiver of the mandatory
enrollment in the MIT Student Extended Insurance Plan if
you already have comparable hospital insurance. If you
are unable to use the online form, contact us at stuplan@med.mit.edu.
If you are not an MIT student you may not complete the
waiver on behalf of a student, even if you have an MIT
certificate. Each student must complete the online waiver
using his or her own certificate.
Wellness Class
Registration
To register for a Center for Health Promotion and Wellness
class.
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