Student Health Care and Counseling Services Forms

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

A

Acknowledgment of Receipt of Notice of Privacy Practices

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

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

C

Consent for Treatment, Payment, and Health Care Operations

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

H

Health Report

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

M

Meningitis Response

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.

P

Notice of Privacy Practices

Read our Notice of Health Care Privacy (HIPPA) Practices to learn how your medical information may be used and disclosed, and how students can get access to this information.

R

Request for Access to Records

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

W

Women's Health Questionnaire (Optional)

Instructions: Please print and send the completed form to the Center. A provider will review the form and the secretary will call you to set up an appointment.

 

Contact Information

For more information about the Health Education and Outreach at SUNY Plattsburgh, please contact:

Rhema Lewis, Health Educator and Outreach Coordinator
Office: Student Activities and Volunteerism
Phone: (518) 564-4830
Email: rhema.lewis@plattsburgh.edu