Student Health and Counseling Center

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Student Health and Counseling Center 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

Student 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 the Meningococcal Disease Sheet and then complete the Meningitis Response form. You can mail, fax or email the printed form to the Center (see addresses below).

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.

 

 

Contact Information

Telephone :
 

  • Student Health: (518) 564-2187
  • Counseling Services: (518) 564-3086
  • Emergency Services: Call 911 or University Police at (518) 564-2022

Fax :

  • Health Center (518) 564-2188
  • Counseling Services (518) 564-2376

Email:

Mailing Address

Student Health and Counseling Center
State University of New York College at Plattsburgh
101 Broad Street
Plattsburgh, NY 12901