Forms

Medical

Please submit completed medical forms by fax to (323) 442-6029 or by e-mail to ecohenshc@med.usc.edu.

HIPAA Privacy Notice
Patient Consent Form
Flu Consent Form
Travel Clinic Form

Counseling

Please submit completed counseling forms by fax to (323) 442-6029 or by e-mail to ecohenshc@med.usc.edu.

Counseling Packet

Health Information Management (Medical Records)

Please submit completed medical records forms by fax to (323) 442-6029 or by e-mail to ecohenshc@med.usc.edu . Please call (323) 442-5631 during clinic hours to check whether we received it. Due to the volume we receive, the estimated timeline that requests are completed is usually between 7-15 working days.

Medical Records Request Form

Insurance

Please submit completed insurance forms by fax to (323) 442-6212 or by e-mail to carabant@usc.edu .

2014-2015 Aetna Plan Document
2013-2014 Summary Of Benefits
2013-2014 Aetna Plan Document