Click on the links to open the forms. Forms are in Adobe Acrobat format. Click here for the latest version of Acrobat.

Clinical Forms: Please print out and complete only if directed to by a nurse or through the online appointment system.

Authorization to Release Medical Information Form - Individuals who would like to request copies of medical records must complete this form. Please complete all sections and provide a signature. You may send this request to us by mail to the Student Health Center, Attn: Lupe Benavides, 601 University Dr., San Marcos, TX 78666; fax 512.245.9288; or drop off at the Medical Records window at the SHC. The cost is $.50 per page plus $5.00 to mail or fax. Normally, we will only fax to another healthcare provider or health care facility when records will not arrive when needed by regular mail. Some requests may take up to 48 hours to process.

QuickPay Credit Card Authorization Form - Completing this form allows parents to provide a method of payment for their student's medical costs without the student having to physically bring their parent's credit card.  Please complete and mail to Texas State University, Student Health Center, Attn: Michelle Nunn, 601 University Drive, San Marcos, Texas 78666, or you may fax to 512.245.1677, attention Michelle Nunn. Please indicate the limit of the authorization in the upper, left corner of the form. The Authorization For Credit Card Use must be signed by the cardholder. All forms received are kept in a secured area within the Cashier Department at the Student Health Center or at the main Cashier Department at J.C. Kellum Building.

The Student Health Center has plans to accept private insurance in the future. At this time, the Health Center will file courtesy insurance claims upon request, which may result in a possible reimbursement. Patients should bring their insurance card to their visit and discuss their options with Cashier staff during check out. Patients may also fill out this form and fax a copy of their insurance card to the Health Center Cashier Department.

 

Parental Consent to Treatment for Minor - Please complete and sign all sections. Return to the SHC by faxing to 512.245.9288, Attn: Medical Records or mail to the Texas State Student Health Center, Attn. Medical Records, 601 University Dr. San Marcos, TX 78666.