HEALTH FORMS
All forms must be returned to the Decker Student Health Services Center unless otherwise noted.
Authorization for Release of Protected Health Information (51k pdf): Use this form to authorize Decker Student Health Services Center staff to release certain health information about you to the party you specify on the release. This isn’t a “blanket” release form; it must specify the illness or injury we may release information about and to whom this information may be given. See Confidentiality for more information.
Health Insurance Waiver Instructions: New domestic undergraduate students should submit an online waiver if they wish to waive automatic enrollment in the University’s health insurance plan. See Health Insurance for more information. THIS WAIVER MUST BE SUBMITTED THROUGH BU BRAIN TO THE STUDENT ACCOUNTS OFFICE BEFORE THE 6TH WEEK OF CLASSES OR YOU’LL BE RESPONSIBLE FOR THE COST OF THE INSURANCE.
International Student Insurance Claim: International students who carry the State University of New York plan through Binghamton’s International Student and Scholar Services office should use this form to make a claim.
Medical History Report (152k pdf): New students should use this form to provide information about their health status/immunizations to the Decker Student Health Services Center prior to registration. See New Students for more information. COMPLETION OF THIS DOCUMENT IS A REQUIREMENT TO REGISTER FOR CLASSES AT BINGHAMTON UNIVERSITY.
Meningitis Information Acknowledgement (41k pdf): New students should use this form to indicate they have read and understand important information about meningitis from the New York State Department of Health (20k pdf). See New Students for more information. COMPLETION OF THIS DOCUMENT IS A REQUIREMENT TO REGISTER FOR CLASSES AT BINGHAMTON UNIVERSITY.
Psychiatric Consultation Questionnaire (228k pdf): Students wishing to be seen for a psychiatric consultation should complete this form prior to their first visit. See Psychiatric Consultations for more information.
Attention Deficit Policy and Agreement (95k pdf): Students wishing to be seen for attention deficit disorder should read and sign this agreement form prior to their first visit.
Tuberculosis Screening Form (98k pdf): New undergraduate students taking 12 or more credits and graduate students taking 9 or more credits should use this form to provide the Decker Student Health Services Center with information about your history of/risk of/immunizations against tuberculosis. See New Students for more information. COMPLETION OF THIS DOCUMENT IS A REQUIREMENT TO REGISTER FOR CLASSES AT BINGHAMTON UNIVERSITY.
Under 18 Consent for Medical/Emergency Treatment (89k pdf): New students who are under age 18 must have their parent/guardian use this form to authorize Decker Student Health Services Center staff to provide medical or emergency treatment to the underage student. See New Students for more information.
