E-mail this pageStudent Health Care and Psychological Services Forms
Note: these forms require the latest version of Acrobat Reader, which is available as a free download.
A
Acknowledgement of Receipt of Notice of Privacy PracticesInstructions: this is for students who have read the Notice of Privacy Practices form and understand it. Please read, print, complete and return to Center.
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Authorization for Use or Disclosure of Protected Health InformationInstructions: this is for students who have read the Notice of Privacy Practices form and understand it. Please read, print, complete and return to Center.
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C
Consent for Treatment, Payment, and Health Care OperationsInstructions: please read, print, complete and return to Center.
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D
Dependent Enrollment Form for Students with Student Accident & Sickness Insurance PlanInstructions: for students with dependents (spouse, children, etc). Please read, print, complete and return to Bursar.
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H
Health ReportInstructions: Please read, print, complete and return to Center.
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M
Meningitis ResponseInstructions: 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.
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N
Notice of Privacy PracticesInstructions: this notice describes how medical information about may be used and disclosed and how students can get access to this information. Please read form.
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R
Request for Access to RecordsThis form provides clarification of the household assets in place at the time of completing your Free Application for Federal Student Aid (FAFSA).
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Contact Information
Location: We are located directly behind Saranac Hall and Macomb Hall. View Center hours and availability.
Telephone
- Student Health: (518) 564-2187
- Psychological Services: (518) 564-3086
- Emergency Services: Call 911 or University Police 564-2022
- Toll-free: (866) 858-4089
Fax:
- Health (518) 564-2188
- Psychological Services (518) 564-2376
E-mail: healthcenter@plattsburgh.edu
Mailing Address:
Center for Student Health & Psychological Services
State University of New York at Plattsburgh
101 Broad Street
Plattsburgh, NY 12901