Forms
| Form | Use |
|---|---|
|
Consent Form for Medical Treatment of Minors (PDF)
|
Parents/legal guardians giving consent for medical treatment of their minor
Patients under the age of 18 declaring emancipation |
| 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.
Instructions/directions for submitting CSU required immunizations. |
|
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.