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Forms
Please find the available forms below. A copy of a current picture identification, including signature (i.e. driver's license, passport) must be included with requests to release PHI or exchange PHI with parents/guardians.
| FORM/request | Description |
|---|---|
| Consent Form for Medical Treatment of Minors (PDF) | Parents/legal guardians giving consent for medical treatment of their minor |
| Minor - Verification of Emancipation | Patients under the age of 18 declaring emancipation |
| Medical Exemption Policy for Required Vaccinations | Policy outlining the criteria and the process for exemptions to immunization requirements based on a medical condition - Available after June 1 |
| Medical Exemption Request Form | Form to be submitted for requesting a medical exemption for required vaccinations based on a medical condition - Available after June 1 |
| Religious Exemption Policy for Required Vaccines | Policy Outlining the criteria and the process for exemptions to immunization requirements based on religious/personal beliefs - Available after June 1 |
| Religious Exemption Request Form for Required Vaccines | Form to be submitted for requesting an exemption for required vaccinations based on religious/personal beliefs - Available after June 1 |
| Medical Records Release Form | To request health information from past visits |
| X-ray Release Form | To request x-rays taken prior to September 2010 |
| Authorization for Disclosure of Protected Health Information to Parents/Guardians | Allow parents/guardians access to student health records |
| Notice of Privacy Practices (PDF) | This notice describes how medical information about you may be used and disclosed, and how you can get access to your information |
| No Show/Late Cancellation Fee Appeal Form | Request fee cancellation because of extenuating circumstances or an error |
| Request for Interview Form | Request interview from Campus Health & Wellbeing |
| Advance Health Care Directive | Advance directives are legal documents that allow you to plan and make your own end-of-life wishes known in the event that you are unable to communicate |
| Patient Rights & Responsibilities | For patient review only |
| Food Journal | Journal for logging eating habits |
| COVID-19 Vaccination Consent and Questionnaire | For students getting a COVID-19 vaccine at Campus Health & Wellbeing |
Health History Form
- The Health History form needs to be filled out prior to your first visit at the Health Center. This form is available in the Health Center Portal.
