Form |
Use |
---|
Hepatitis B and Measles/Rubella Immunization Form (PDF) |
Instructions/directions for submitting CSU required immunizations. |
Medical Records Release Form (PDF) |
To request health information from past visits. |
X-ray Release Form (PDF) |
To request x-rays taken prior to September 2010. |
Authorization for Disclosure of Protected Health Information to Parents/Guardians (PDF) |
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 |
Use this form to appeal a no show or late cancellation fee. |
Request for Interview Form |
To request a media or other interview with our staff. |
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 for |