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Health Assessment Forms
The following forms must be completed:
All three forms must be on record (students under 18 years of age must have the Health Assessment Form signed by a guardian).
Note: these forms must be printed and then completed, signed and brought with you at the time treatment/immunizations are
given.
Graduate Insurance Waiver/Enrollment Form
All main campus graduate students enrolled for 8 + credit hours are automatically enrolled in the BGSU insurance plan. If
you are covered by another comparable plan and do not need the BGSU plan, you need to complete and sign a waiver. You can
also choose the enrollment option on the form. If you would still like to purchase the insurance, please email studentins@bgsu.edu for that enrollment form.
International Student Enrollment
All international students/scholars (F-1, J-1 visa holders) are required to have acceptable approved health insurance while
enrolled at BGSU. This includes students registered for thesis hour(s), co-ops and internships. Please contact the Student
Insurance Office at 419-372-7495 or email studentins@bgsu.edu for information. International students must go to the Student Insurance Office to complete the appropriate forms.
Pharmacy Patient Demographic Information
Employees, their spouses and their dependents may purchase their new or transferred prescriptions through our BGSU Pharmacy.
If you would like to utilize this benefit you can complete the Patient Demographic Information Form, print it and fax it to the Pharmacy Dept. at 419-372-7999.
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Pharmacy Readyfill
The Readyfill system can be used by faculty, staff and students to refill any prescription that has previously been filled
at the BGSU SHS Pharmacy, and whose prescription label indicates one or more remaining refills. You may click here to obtain the Readyfill Form. Have your prescription label handy so you can enter your prescription number and remaining
refills.
Authorization for Release of Medical Information
The Authorization for Release of Medical Information form must be completed by the patient when they would like a copy of their medical records provided to them or another healthcare
provider. This form must also be completed by the patient when giving the Student Health Service permission to disclose personal
health information for reasons other than treatment, payment or health care operations. There may be a charge for copies .
Authorization to Communicate by Email
In recognition of the fact that email is the preferred form of communication for many patients and staff, email between patients
and staff is permitted within procedural guidelines intended to provide confidentiality and security to the fullest extent
possible. The Authorization to Communicate by Email form must be completed, signed and returned to the Student Health Service prior to email communication.
Request for Limitations
The Request for Limitations form must be completed by the patient when they are requesting a limitation to the routine use of their personal health information
for treatment, payment or health care operations.
Request for Amendment
The Request for Amendment form must be completed by the patient when the patient would like to request a change in their personal health information.
Request for Alternative Communication
The Request for Alternative Communication form must be completed by the patient if the patient would like to request to receive information from us by alternative means
or at alternative locations.
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