Forms

Please complete the required forms listed under Medical Clearances in your Charger Health Portal or print out the forms below, complete, and bring to your appointment.

• Information (Demographics) Sheet
• Medical History
• Third Party Communications/Privacy Information
• Patient Rights and Privacy Notice
• FOR NURSING FACULTY ONLY - Annual Questionnaire for Employees with Positive TB Skin Test

 Billing:

If you received a bill for services not covered by your insurance plan (or copay/deductible) or for past due accounts, you can choose to pay by:

• Credit Card or HSA/FSA card in the clinic or on the phone.  Payments can be processed in the clinic Monday thru Friday, between 8am-11:30am or 1pm-4pm.  Stop by or call 256-824-5495
• or  Payroll Deduction.  If you choose the payroll deduction option, please fill out the top portion and forward to the Faculty and Staff Clinic. 
  • You can send the form to us by either:
    • A secure message attachment using the billing/insurance option in your patient portal, or
    • Drop off in person or by Campus Mail to UAH Health Services, Wilson Hall 327, or
    • email to fsc@uah.edu