Forms

Medical

Allergy Desensitization Program Criteria Information Sheet

Allergy Desensitization Injection Program; Onset of Immunotherapy

Health Information Management – UPC Campus

(Medical Records)
Authorization for Disclosure of Medical Information (From ESH)

Authorization For Disclosure of Medical Information (incoming to ESH)

Authorization – Verbal Communication with Healthcare Provider

Medical Excuse Policy

3rd Party Consent to Treat a Minor (required for 17 years and younger)

Self Sufficient Minor Status Verification

Health Information Management – HSC Campus

(Medical and Behavioral Health Records)
Per our policy, “Medical records retention is based on the type of medical record. Hard copy medical records are retained for ten years from last visit date. Records older than ten years from last visit date are identified for destruction and are performed by the secure, offsite record storage facility.”

For more information, view our entire policy on Medical Record Retention.

To request copies of your health information records, please complete a “Medical Records Release Form” OR a “Release of Behavioral Health Information” form. Once you have completed the form, please fax to (213) 740-4961 or e-mail to eshchim@usc.edu. It is important for you to include your contact information for us to be able to contact you regarding your request. Once you have sent the complete form, please call (213) 740-0206 during clinic hours to check whether we received it. Due to the volume of requests we receive, the estimated timeline that requests are completed is usually between 7-15 working days.

Authorization for Disclosure of Medical Information (From ESH)
Authorization For Disclosure of Medical Information (incoming to ESH)
Behavioral Health Release of Information
Notice of Disclosure of Medical Information
Requesting Medical Records from Other Providers

Health Insurance

Aetna Medical Claim Form

Aetna Prescription Drug Claim Form

DeltaDentalclaimform_ca

Dental Enrollment Form

Studying Abroad

Medical Claim Form

Travel History

Dietetic Services and Nutrition

Daily Food Journal

Feedback

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