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Health Care and Psychological Services Forms

Note: these forms require the latest version of Acrobat Reader, which is available as a free download.

Acknowledgement of Receipt of Notice of Privacy Practices Form

Instructions: this is for students who have read the Notice of Privacy Practices form and understand it. Please read, print, complete and return to Center.

Authorization for Use or Disclosure of Protected Health Information Form

Instructions: please read, print, complete and return to Center.

Consent for Treatment, Payment, and Health Care Operations Form

Instructions: please read, print, complete and return to Center.

Dependent Enrollment Form for Students with Student Accident & Sickness Insurance Plan

Instructions: for students with dependents (spouse, children, etc). Please read, print, complete and return to Bursar.

Health Report

Instructions: Please read, print, complete and return to Center.

Meningitis Response Form

Instructions: New York State Public Law states that all students enrolled in 6 or more credit hours complete this form for their medical records. Please read, print, complete and return to Center.

Notice of Privacy Practices Form

Instructions: this notice describes how medical information about may be used and disclosed and how students can get access to this information. Please read form.

Request for Access to Records Form

Instructions: For release of your protected health information, please read, print, complete and return to Center.

Student Rights and Responsibilities Form

Instructions: This is a document outlining the expectations, rights, responsibilities and quality of Center for Student Health and Psychological Services care.

Contact Information

Location: We are located directly behind Saranac Hall and Macomb Hall. View Center hours and availability.

Telephone

Fax:

E-mail: healthcenter@plattsburgh.edu

Mailing Address:

Center for Student Health & Psychological Services
State University of New York at Plattsburgh
101 Broad Street
Plattsburgh, NY 12901

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