UHC Forms

Below you will find a number of forms which you may print out, fill in, and bring into the UHC to expediate your next visit. All documents are in the .pdf format and require a .pdf reader such as Adobe Acrobat to view. For a free download of Adobe Acrobat visit the Adobe Website.

Clinics

• Medical History Form (Bring to your first UHC visit)
• Women's Health History Form (For yearly examinations)
• Allergy History Form (Bring to your first visit for allergy injections)

Pre-Enrollment Health Requirement Form

• Pre-Enrollment Health Requirment Form

Registration and Insurance

- Bring to your first UHC visit of each academic year

• UNL Healthy Option Student Insurance Information Form
• Insurance Information Form (For all other insurances, i.e. Blue Cross/Blue Shield, Coventry, Midland’s Choice, Tricare, etc.)

Medical Records

- Permission to have your medical records released

• Authorization for Release of Information - Form A (From UHC to outside provider or other entity)
• Authorization for Release of Information - Form B (From outside provider to UHC)

Studying Abroad

• History and Health Clearance Form

Counseling and Psychological Services

• Confidential Personal Data Sheet
• Presentating Problems
• Repeat Client