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Student Health & Counseling Forms

Before arriving on campus, ALL new students must send their completed Student Health Report, including immunization records and proof of covid vaccines (including booster, if eligible), to: [email protected] or fax 518-564-2188, or by mail to Student Health and Counseling Center, 101 Broad St., Plattsburgh, N.Y. 12901 

Student Health Record

Instructions: Please download, read, complete and return to the health center as soon as possible.

Alphabetical List of All Forms

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

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