FORMS- DUE April 11, 2016


(Do not staple, paper clip or double side forms. Original forms must be mailed, scanned/emailed forms will not be accepted.)


All forms must be completed using your legal name as indicated on your Social Security Card.

NOTE: The "Health Statement" requires a physical exam, supporting documentation for TB Skin Tests, labs & vaccinations. Please plan on meeting the requirements while you still have access to healthcare.

Employee Identification Number/Start Date/Date of Hire/Qualifying Event Date will be filled in by HR.

Print, legibly complete and mail all original forms to:

UCSF Fresno Center
Attn: Dyan Ruelas
155 N. Fresno Street, #251
Fresno, CA 93701

Required Forms


For MDs Only


For DOs Only


If Applicable Forms



Nonresident Alien Forms (if applicable)