HEALTH FORMS
All forms must be returned to University Health Service unless otherwise noted.
Authorization for Release of Protected Health Information (14k pdf): Use this form to authorize University Health Service 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 (172k pdf): New domestic undergraduate students should use this form if they wish to waive automatic enrollment in the University’s health insurance plan. See Health Insurance for more information. THIS FORM MUST BE RETURNED 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 (157k pdf): New students should use this form to provide information about their health status/immunizations to University Health Service 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 (22k 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 (145k 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.
Tuberculosis Screening Form (74k pdf): New undergraduate students taking 12 or more credits and graduate students taking 9 or more credits should use this form to provide University Health Service 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 (43k pdf): New students who are under age 18 must have their parent/guardian use this form to authorize University Health Service to provide medical or emergency treatment to the underage student. See New Students for more information.
