Student Health Services (SHS) Forms
- Request Consent for Release of Information FROM Student Health Services [PDF]
- Request Consent for Release of Information TO Student Health Services [PDF]
- Cold and Flu Self-Care Cafe Menu [PDF]
- Consent for Telemedicine Treatment [PDF]
- Medical Immunization Exemption Request Form [PDF]
- Grad Student Attestation Form [PDF]
Counseling and Psychological Services (CAPS) Forms
- Bias Incident Form
- Consent for Telepsychology/Telepsychiatry Treatment Form [PDF]
- Food Insecurity Form
- Harassment, Discrimination, Sexual Misconduct, and Retaliation Report Form
- Request Consent for Release of Information-Counseling and Psychological Service [PDF]
- Student of Concern Report
- Supervisory Disclosure and Consent Form [PDF]
Release of Medical and/or Psychological Records or Information
Medical and/or Psychological records are confidential by law and are not released to anyone, including parents, spouse, friend, off-campus medical or mental health providers, and/or University personnel, without the written consent of the student. A completed Consent to Release of Information form with student’s official signature is required before any medical and/or psychological records can be sent, requested from, or discussed with a third party (off-campus mental health provider or facility, parent, other). A notary verifying student’s (or former student’s) signature may be required.
- Complete the appropriate Consent for Release of Information for SHS or CAPS from above.
- Include contact phone numbers in case there are any questions.
- Sign requested form. (We will be unable to process your request without an official signature. If your signature is not verified and you are away for campus and cannot come into the Cowell Center to complete the form, you will be required to have the Consent to Release of Information form notarized.)
- Fax Notarized form to:
(408) 554-2376 for SHS
(408) 554-5454 for CAPS
Note: Photocopying of medical records for 5 pages or less is Free and 6 pages or more is $10.00
Eligible students may request an office visit fee waiver to exempt them from Student Health Services or Counseling and Psychological Office Visit Fees. Exemption status is proferred to PELL Grant Recipients and other students of pre-identified need.
If you have been informed that you are eligible for an Office Visit FEE WAIVER, please complete the form below and email it to email@example.com.