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Forms and Publications

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General MIT Medical publications and forms
General medical and health care forms
Students
Employees
Children
Affiliates

General MIT Medical Forms and Publications

• Primary care provider choice
  • Primary care provider choice form (online form)
• Health history forms
• Adult Patient Health History in English, Chinese, Japanese, Russian, Spanish, and Korean
• Adult Dental Patient Health History in English, Chinese, Japanese, Korean, and Spanish
• Pediatric Health History in English, Chinese, Japanese, Korean, Russian, and Spanish
• Medical record forms
  • Authorization for Release of Protected Health Information
    (Medical Record) by MIT Medical
  • Authorization for Release of Protected Health Information
    (Dental Record) by MIT Medical
  • Authorization for Release of Protected Health Information
    (Mental Health Record) by MIT Medical
  • Authorization for Release of Protected Health Information
    (Medical Record) to MIT Medical
  • Authorization for Release of Protected Health Information
    (Mental Health Record) to MIT Medical
  • Request for Amendment of Protected Health Information
• Patient privacy / advocacy / rights
  • Notice of Privacy Practices – MIT Medical Department
  • Notice of Privacy Practices – MIT Health Plans (Traditional, Student Extended Insurance, Affiliate Extended Insurance)
  • Patient Advocacy in English, Chinese, Japanese, and Korean
  • Patient Rights and Responsibilities in English, Chinese (simplified), Chinese (traditional), Japanese, and Korean
• MIT Pharmacy forms
• Home Delivery from MIT Pharmacy (request form)
• Release for Pharmacy Patient Prescription Profile
• Wellness class registration
  • Class registration (Community Wellness at MIT Medical)

General medical and health care forms

• Massachusetts
  • Health Care Proxy

Students

• Medical Report Forms
  • Student Medical Report Form – for students entering in summer or fall 2012
  • Student Medical Report Form FAQ
• Health plans
• Student Health Plans Enrollment Form
• Student Health Plans – Overview
• More details:
  • Student Health Plan Benefit Description – a more detailed explanation of services covered at MIT Medical under the MIT Student Medical Plan
  • Blue Cross Preferred Provider Benefit Description – details the covered services and benefits administered by Blue Cross Blue Shield of Massachusetts
  • Student Health Plan addendum – provides information about services provided by MIT Medical that are covered under the Student Extended Insurance Plan as well as other benefits administered by the MIT Health Plans office
• Older documents:
  • Student Health Plans – Overview
  • Student Medical Plan – Benefit Description (2010-11)
  • Student Extended Insurance Plan – Benefit Description (2010-11)
• Affidavit of Spousal-Equivalent Partnership
• Express Scripts claim form (for prescription appliances and prescription drugs purchased on or after September 1, 2009)
  
• Blue Cross Blue Shield subscriber claim form (mental health)

Employees

• MIT Traditional Health Plan
  • 2013
    • 2013 MIT Traditional Health Plan – Brochure
    • 2013 MIT Traditional Health Plan – Blue Cross Network Blue Benefit Description
  • 2012
    • 2012 MIT Traditional Health Plan – Member Handbook
    • 2012 MIT Traditional Health Plan – Brochure
    • 2012 MIT Traditional Health Plan – Blue Cross Network Blue Benefit Description
  • 2011
    • 2011 MIT Traditional Health Plan – Member Handbook
    • 2011 MIT Traditional Health Plan – Brochure
    • 2011 MIT Traditional Health Plan – Blue Cross Network Blue Benefit Description
    • 2011 MIT Traditional Health Plan – MIT addendum
      
  • 2010
    • 2010 MIT Traditional Health Plan – Benefit Plan Description
    • 2010 MIT Traditional Health Plan – Member Handbook
    • 2010 MIT Traditional Health Plan – Brochure
• MIT Choice Plan
  • MIT Choice Plan – Summary of Benefits
• Other MIT Health Plan resources
• Physician Order Form (for patients who have any MIT-sponsored health plan and who want to have tests ordered by their outside provider done at MIT Medical)
• Express Scripts Drug Claim Form (for prescription drugs)
• Fitness/weight loss benefit brochure
  
• Blue Cross Blue Shield forms and brochures
  • Subscriber submit claim form
  • Fitness benefit form
  • Weight-loss benefit form

Children

• Consent for treatment of a minor (a parental consent allowing another specific adult(s) to authorize medical care for a child in the parent's absence)
• How to use pediatrics at MIT Medical
• Pediatric health history form in English, Chinese, Japanese, Russian, Spanish, and Korean
• Massachusetts certificate of immunization
• Massachusetts school health record form
• Massachusetts school immunization requirements

Affiliates

• Health Plans
• MIT Affiliate Health Plan Overview 2012-13
• More details:
  • Affiliate Health Plan Benefit Description (2011-12) – a more detailed explanation of services covered at MIT Medical under the MIT Affiliate Medical Plan
  • Blue Cross Preferred Provider Benefit Description – details the covered services and benefits administered by Blue Cross Blue Shield of Massachusetts for both students and affiliates.
  • Affiliate Health Plan addendum – provides information about services provided by MIT Medical that are covered under the Student Extended Insurance Plan as well as other benefits administered by the MIT Health Plans office
  • 2010-11 Affiliate Health Plan Overview
• Affiliate Waiver Request Form
• Affidavit of Spousal-Equivalent Partnership
• Express Scripts Drug Claim Form (for prescription drugs)
  
• Blue Cross Blue Shield Subscriber Claim Form
  

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