Forms + Brochures
Student Health Center Brochure
Immunization Form
LMU requires undergraduates taking 6 or more units to complete the attached immunization form and return it to the Student Health Center. The attached form can be downloaded and faxed to (310) 338-4417 or mailed to Student Health Services. If you would like to read more information about immunizations, contact the Centers for Disease Control at www.cdc.gov/nip
Exemption Affidavit Regarding Immunizations
If you are requesting exemption from the LMU immunization requirements for vaccine preventable diseases you will need to complete this form. In lieu of the Mantoux Tuberculosis Skin Test you will be required to forward the results of a recent chest x-ray (within one year of the being of school).
Medical Release Form
To obtain copies of your medical records, print out and complete the attached form. Fax to 1-310-338-4417 or mail the form with a copy of your driver's license to Student Health Services. Please allow 7 - 10 days to receive the requested medical records. There will be a $10.00 charge for additional and future copies of this same information, so please keep a copy for your personal records.
United HealthCare Extension of Benefits Form
All Insured Persons who have been continously insured under the school's regular student Policy for at least 6 consecutive months and who no longer meet the Eligibility requirements under the Policy (due to graduation, reduction in credit hours or other reasons) are eligible to continue their coverage for a period of not more than six months under the school's policy in effect. If an Insured Person is still eligible for continuation at the beginning of the next Policy Year, the Insured must purshase coverage under the new policy as chosen by the school. Coverage under the new policy is subject to the rates and benefits selected by the school for that Policy Year.
Application must be made and premium must be paid directly to Student Insurance and be received within 14 days after the expiration date of your student coverage. For futher information on the continuation privilege, please contact United Healthcare Student Resources at 1-877-848-8472.