Health Clearance Form
Once you have been officially accepted as an inbound exchange student to UHM, please remember to complete the Health Clearance Form. Please send the completed form to University Health Services as soon as you can (it is OK to submit the form after the deadline, but important to submit it before courses registration begins). University Health Services Manoa does NOT accept this form by email - please mail or fax. Please do NOT email your form to MIX; it must be submitted directly to University Health Services.
The Health Clearance Form is five pages long, but you only need to submit two pages. The first page contains useful information. The two pages that you need to return to University Health Services Manoa are pages 2 and 3. These are the “Health Clearance Form” and the “Immunization Record,” and are actually numbered “1 of 2” and “2 of 2."
You may disregard part I ("Tuberculosis Control"). When you arrive to UHM, you will be required to report to University Health Services tor a tuberculin (TB) skin test.
- You must complete Part II ("MMR") and provide your MMR (measles, mumps, rubella) immunization record. You can either A) have your health care provider complete this page of the Health Clearance Form, B) submit a copy of your school or public health immunization record, or C) submit a copy of a health care provider's record.
- The "Health Insurance" information on page 4 is primarily intended for U.S. citizens; unless you are a U.S. citizen, you do not need to complete the "Health Insurance Information Sheet" on page 5.
Health Insurance for International Students
International students must meet certain minimum health insurance coverage requirements. You will find more information about this at the UHSM website. Use the link on the left for 'International Student Insurance.' There you will find the requirements (click link for “Insurance Requirements”) for both J-1 and F-1 students. NOTE: You are a J-1 student if you received a DS-2019 form; you are an F-1 student if you received an I-20 form.
J-1 students can purchase the UH Student Plan (HMSA) or have your own insurance provider complete the J-1 Health Insurance Provider Certification Form. Please also read the J-1 FAQ on the ISS website, and sign a Health Insurance Requirements Acknowledgment Form. At your Visa Clearance Session, you must submit proof of health insurance to International Student Services (ISS) to receive your health insurance clearance. Questions? Contact ISS at firstname.lastname@example.org.
F-1 students can purchase the UH Student Plan (HMSA) or have your insurance provider complete the F-1 Student Acknowledgement & Insurance Provider Certification Form in order to prove that your current health insurance policy meets UHM's requirements. Upon arrival to UHM, you must submit proof of health insurance to the Student Health Insurance Office (QLC 313) to receive your health insurance clearance. Questions? Contact the Student Health Insurance office (QLC room 313-D) at email@example.com.
Alternate Health Insurance: If you do not plan to purchase the UH Student Plan and are considering purchasing alternative health insurance, ISS acknowledges an alternative plan that meets both the J-1 federal and F-1 UH policy student health insurance standards.