Forms and Publications
For PDF documents below, you’ll need Adobe Reader.
Students
- Physician Choice
- Physician Choice Form (online)
- Medical Report Forms
- Health plans
- Student Health Plans – Overview
- Student Medical Plan – Summary Plan Description
- Student Extended Insurance Plan – Summary Plan Description
- Student Health Plans Enrollment Form 2008-09
- Affidavit of Spousal-Equivalent Partnership
- MIT Health Plans claim form (for prescription appliances and prescription drug claims for the MIT Student Extended Insurance Plan and the MIT Affiliate Extended Insurance Plan; for prescription drugs and acupuncture claims for the Traditional and Flexible MIT Health Plans)
- Blue Cross Blue Shield Subscriber Claim Form (mental health
Employees
- Physician Choice
- Physician Choice Form (online)
- Health Plans
- 2009 MIT Traditional Health Plan brochure
- 2009 MIT Flexible Health Plan brochure
- 2009 MIT Traditional Health Plan – Summary Plan Description
- 2009 MIT Flexible Health Plan – Summary Plan Description
- Primary Care Benefit (provider visit benefit for all employees, regardless of whether they are enrolled in an MIT health plan)
- Affidavit of Spousal-Equivalent Partnership
- MIT Health Plans claim form (for prescription appliances and prescription drug claims for the MIT Student Extended Insurance Plan and the MIT Affiliate Extended Insurance Plan; for prescription drugs and acupuncture claims for the Traditional and Flexible MIT Health Plans)
- Blue Cross Blue Shield Subscriber Claim Form (mental health)
- 2008 Benefits Information:
Affiliates
- Physician Choice
- Physician Choice Form (online)
- Health Plans
- MIT Affiliate Health Plan – Overview
- MIT Affiliate Insurance Plan – Summary Plan Description
- MIT Affiliate Extended Health Plan – Summary Plan Description
- MIT Affiliate Health Insurance Waiver Form
- Affidavit of Spousal-Equivalent Partnership
- MIT Health Plans claim form (for prescription appliances and prescription drug claims for the MIT Student Extended Insurance Plan and the MIT Affiliate Extended Insurance Plan; for prescription drugs and acupuncture claims for the Traditional and Flexible MIT Health Plans)
- Blue Cross Blue Shield Subscriber Claim Form (mental health)
Other MIT Medical Publications and Forms
- Patient Privacy / Advocacy / Rights
- Notice of Privacy Practices - MIT Medical Department
- Notice of Privacy Practices - MIT Health Plans (Traditional, Flexible, Student Extended Insurance, Affiliate Extended Insurance)
- Authorization for Use and Disclosure of Protected Health Information (medical record release form)
- Authorization for Use and Disclosure of Protected Health Information – Mental Health Record (mental health record release form)
- Request for Amendment of Protected Health Information
- Patient Advocacy in English, Chinese, Japanese, and Korean
- Patient Rights and Responsibilities in English, Chinese (simplified), Chinese (traditional), Japanese, and Korean
- Health History Forms
- Patient Health History in English, Chinese, Japanese, and Korean
- Dental Patient Health History in English, Chinese, Japanese, Korean, and Spanish
- Pediatric Health History in English, Chinese, Japanese, and Korean
- MIT Pharmacy
- Wellness class registration
- Class registration form (Center for Health Promotion & Wellness)
- Class registration form (Center for Health Promotion & Wellness)
![[MIT logo]](/images/logo_mit.gif){kind=logo}
