Info

Phone: (805) 756-1211
Fax:     (805) 756-5298

8 am - 4:30 pm | M, Tu, Th, Fri
9 am - 4:30 pm | Wed

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Building 27

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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 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 

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.

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