Forms and Memos
- Authorization and Consent for Treatment of Minors (PDF)
* - Health Insurance Information Sheet (PDF) *
- Patient Rights and Responsibilities & UHSM Notice of Privacy Practices (PDF) *
- Release of Information Authorization Form (PDF) *
- Request for Non-Student Eligibility for University Student Health Insurance Form (PDF) *
- Student Health Advisory Council (SHAC) Application Form (PDF) *
International Students: Forms and Memos
F-1 Student Acknowledgement & Insurance Provider Certification Form and Instructions (PDF) *
- All UH Manoa F-1 students need to complete this form to receive your health insurance clearance.
- Read the instructions to make sure you have all the appropriate forms and documentation needed in order to prevent any delays in receiving your health insurance clearance.
IMPORTANT : If your plan does not meet the minimum levels of coverage required or your insurance company will not complete and sign the F-1 Student Acknowledgement & Insurance Provider Certification Form, then your plan will not be accepted for health insurance clearance.
F-1 Student Acknowledgement & Insurance Waiver Form (PDF) *
If you are requesting a waiver to the UH Manoa's health insurance requirement because you will not physically be in the United States for the Fall and/or Spring semesters, complete this waiver form.
- Read the instructions to make sure you have all the appropriate forms and documentation needed in order to prevent any delays in receiving your health insurance clearance.
For Students on the UH Employer/Employee Health Insurance Plan (through EUTF)
MEMO (for EUTF members) (PDF) *
Have your UH department complete and sign this MEMO:
- If you have applied or will be applying for the EUTF plan
- If you are currently on the EUTF plan and you have new appointment dates
