Forms

The Immunization Record must be completed and signed by a physician, nurse practitioner, or physician assistant. All information must be legible and vaccine dates must contain month/day/year. Immunization record forms must be returned by fax, mail, or dropped off in person to Student Health Service.

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Report of Medical History

The required Report of Medical History form is for the student to self report (or parent to report if the student is under age 18) information regarding medical conditions, allergies, medications, and insurance coverage. Students must complete the Report of Medical History electronically by logging on to myPIRATEchart and selecting “Medical History” from the left hand menu.

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Parental Consent for Treatment of Students Under 18

The Parental Consent for Treatment of Students Under 18 is required and must be on file for any student under 18 years of age. A parent or guardian must fill out and sign the consent.

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Medical Record Release Forms

Patients should use the Individual Request for Access to PHI to have records sent directly to themselves. Allow 2-3 business days for records to be sent. There is a Charge for Medical Record Copies when releasing them directly to the patient.

Authorization for Use and Disclosure of Protected Health Information

The Authorization for Use and Disclosure should be used if a patient is requesting records be sent to another medical office or other third party entity (insurance, law firm, job site, etc).  Allow 2-3 business days for records to be sent. There is no charge for records sent directly to another facility from Student Health Service.

Outside Lab Order Form

Students who have lab orders from another provider can have their lab work performed conveniently at SHS. The Outside Lab Order Form should be filled out by the ordering provider; ALL fields are required for SHS before an appointment can be made at SHS to perform the labwork. Once SHS verifies that all information has been received, the student will be contacted by SHS staff to schedule their lab appointment.