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

Report of Medical History

Asthma History Form

Psychiatry Clinic Intake Questionnaire

Psychiatry Services Patient Care Contract

Administrative Forms:

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 medical provider or health care facility and only when records will not arrive when needed by regular mail. Some requests may take up to 48 hours to process.

Credit Card Authorization Form - 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) 245-3918, 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.

Request for Waiver/Refund of Insurance Premium Form - International students who wish to waive the health insurance fee from their registration bill should complete and submit this form to the Student Health Center prior to their payment deadline. This form must be submitted for each semester. For more information about the insurance waiver process, click here.

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.

Last Modified: August 15, 2007