Please read this note to users sending or requesting forms with private health information (PHI) via email.

Policy Information Regarding:

• Medical Absence notes for missed classes/exams
• Prescriptions for ADHD medications
• Advanced directives and medical power of attorney

Medical Forms

• Allergy Desensitization Information and Forms
• Medical Absence Form (Self Verification)

Health Information Management (Medical Records)

• Instructions: Requesting medical records
• Authorization for Disclosure of Health Information
• Authorization – Verbal Communication with Healthcare Provider
• 3rd Party Consent to Treat a Minor (required for students under age 18)
• Self Sufficient Minor Status Verification
• Request for Addendum for Clinical Notes

Health Insurance/Billing Forms

• Medical Claim Forms (Aetna)
• Billing Dispute Form (Student Health)
• Dental: Find updated claims information through the Delta Dental patient portal.
• Medical Claim Form for study abroad programs

Immunization Exemption Forms

For measles, mumps, varicella, meningococcal disease vaccines

• Medical Exemption for Immunization
• Religious Exemption for Immunization

Influenza Forms

• FLU: Medical Exemption (Fillable Digital Fields)
• FLU: Religious/Philosophical Exemption (Fillable Digital FIelds)
• FLU: Attestation (for Employees)

USC COVID-19 Exemption Forms

See the University of Southern California COVID-19 vaccination policy. The forms listed in this section may be completed and uploaded for review to MySHR.

• COVID-19: Medical Exemption to requirement (for Students)
• COVID-19: Medical Exemption to requirement (for Faculty and Staff)
• COVID-19: Religious Exemption to requirement
• Solicitud de exención religiosa para la vacunación de COVID-19
• Solicitud de exención médica para la vacunación de COVID-19
• Scarcity Exemption Form (for individuals outside of the U.S.)