Parents/legal guardians giving consent for medical treatment of their minor
Patients under the age of 18 declaring emancipation
Instructions/directions for submitting CSU required immunizations.
|Medical Exemption Request Form||
Form to be submitted for requesting a medical exemption for required vaccinations based on a medical condition.
|Medical Exemption Policy for Required Vaccinations||Policy outlining the criteria and the process for exemptions to immunization requirements based on a medical condition.|
|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|
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.