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Forms

Medical Services

Allergy History and Therapy Form This document uses Adobe Acrobat

Travel History Form This document uses Adobe Acrobat

Counseling Services

 

Health Promotion and Prevention Services

Peer Health Educator (PHE) Application This document uses Adobe Acrobat

Health Insurance and Waivers

Claim Form, medical This document uses Adobe Acrobat

Claim Form, dental This document uses Adobe Acrobat

Pre-Authorization Form, dental This document uses Adobe Acrobat

USC Student Health Insurance Plan  This document uses Adobe Acrobat

Health Insurance Waiver Form This document uses Adobe Acrobat

Enrollment Form, medical This document uses Adobe Acrobat

Enrollment Form, medical (Off Campus) This document uses Adobe Acrobat

Medical Benefit Chart for Students  This document uses Adobe Acrobat

Medical Benefit Chart for Off-Campus Students  This document uses Adobe Acrobat

Medical Benefit Chart for Students Studying Overseas  This document uses Adobe Acrobat

Medical Benefit Chart for GAP Insurance  This document uses Adobe Acrobat

Pharmacy Benefits for Students  This document uses Adobe Acrobat

Pharmacy Benefits for Dependents  This document uses Adobe Acrobat

Pharmacy Benefits for Off-Campus Students  This document uses Adobe Acrobat

Pharmacy Benefits for GAP Insurance  This document uses Adobe Acrobat

Pharmacy Claim Form  This document uses Adobe Acrobat

Power Select HMO, USC Dependents  This document uses Adobe Acrobat

Optional Student Dental Plan Enrollment This document uses Adobe Acrobat

Optional Dental Plan Benefit Chart  This document uses Adobe Acrobat

 

These forms are presented using Adobe Acrobat. You will need a copy of Acrobat in order to view or print these files. You can download Acrobat for free by choosing one of the methods below:

Download Acrobat from Adobe
Click here to get Adobe Acrobat

Download Acrobat from ISD

 

 

 

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University of Southern California University of Southern California