Student Health & Counseling Forms

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Student Health Record

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• Domestic Student Health Record
• International Student Health Record

Email your completed student health record to [email protected]. You may also send by:

Fax: 518-564-2188

Mail:
Student Health and Counseling Center
101 Broad St.
Plattsburgh, NY 12901

Note: Students who are fully remote and have no physical presence on campus are not required to send records.

Alphabetical List of All Forms

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A

Acknowledgment of Receipt of Notice of Privacy Practices Form 

Appeal Form for Fees 

Authorization for Use or Disclosure of Protected Health Information Form 

C

Consent for Treatment, Payment, and Health Care Operation Form 

I

Informed Consent for TeleCounseling and TelePsychiatry

International Student Health Record

M

Meningococcal Disease Fact Sheet 

Meningitis Response Form 

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

No Show Appeal Form

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