Click on the links to open the forms. Forms are in Adobe Acrobat format. Click here for the latest version of Acrobat.
Authorization to Release Medical Information Form(s) - Individuals who would like to request copies of medical records from the Health Center, OR have staff request medical records be sent to the Health Center, must complete the appropriate form. All requests should include a copy of a photo ID (ie. Driver’s license or Student ID).
Please note electronic signatures are not accepted.
- Request Records from the Health Center be sent to another Medical Provider OR Patients can request a copy
Please complete this form if you need the Health Information Management Staff to send your records to another provider; OR to request records be sent to you or to someone other than a medical provider.
- Request Records from Another Provider be sent to the Health Center.
Please complete this form(s) if you need the Health Information Management Staff to request your records from another provider in order to continue care at the Student Health Center.