Forms and Publications
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General MIT Medical publications and forms
Children
Students
Employees
Affiliates
General MIT Medical Publications and Forms
- General information about MIT Medical
- Physician choice
- Physician Choice Form (web form)
- 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
- Medical record release authorizations
- 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
- Authorization for Use and Disclosure of Protected Health Information – Mental Health Record
- 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 Korea
- MIT Pharmacy forms
- Wellness class registration
- Class registration form (Center for Health Promotion & Wellness)
Children
- How to Use Pediatrics at MIT Medical
- Pediatric Health History in English, Chinese, Japanese, and Korean
- Massachusetts Certificate of Immunization
- Massachusetts School Health Record Form
- Massachusetts School Immunization Requirements
Students
- 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 2009-10
- Affidavit of Spousal-Equivalent Partnership
- ESI Drug Claim Form (for prescription appliances and prescription drugs purchased on or after September 1, 2009)
- MIT Health Plans claim form (for prescription appliances and prescription drugs purchased before September 1, 2009)
- Blue Cross Blue Shield Subscriber Claim Form (mental health)
Employees
- 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
- ESI Drug Claim Form (for prescription appliances and prescription drugs)
- MIT Health Plans claim form (for acupuncture services)
- Blue Cross Blue Shield Subscriber Claim Form (mental health)
- 2008 Benefits Information:
Affiliates
- 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
- ESI Drug Claim Form (for prescription appliances and prescription drugs purchased on or after September 1, 2009)
- MIT Health Plans claim form (for acupuncture services, prescription appliances and prescription drugs purchased before September 1, 2009)
- Blue
Cross Blue Shield Subscriber Claim Form (mental health)
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