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Student Health and Counseling Forms


Before you arrive on campus, you must send your Student Health Report to the Student Health Center Office via email, fax or by mail.

Alphabetical List of All Forms

A

Acknowledgment of Receipt of Notice of Privacy Practices Form (PDF)

Appeal Form for Fees

 (PDF)

Authorization for Use or Disclosure of Protected Health Information Form (PDF)

C

Consent for Treatment, Payment, and Health Care Operation Form (PDF)

M

Meningococcal Disease Fact Sheet (NYS Dept. of Health) (PDF)

Meningitis Response Form (PDF)

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.

N

Notice of Privacy Practices

S

Student Health Center Portal

A module that enables secure messaging between students and medical providers. Providers can send messages. attach medical reports and answer questions the student might have regarding the results. Students can request prescription refills and download and print their immunization records and new students can submit required medical information. To access the portal you need your SUNY Plattsburgh NetID and password.

Student Health Record

Instructions: Please read, print, complete and return to Center as soon as possible.

Student Health Record (Domestic) (PDF)

Student Health Record (International) (PDF)

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