Forms

Health Promotion Office

• Programs and Activities Without Substances (PAWS) Funding Application (PDF)

Immunization

• Health History Questionnaire: this form is not available online. Contact us to request a form.
• Student Immunization Record (PDF)
• Meningitis Response (PDF)

Student Health Insurance Services

• Insurance Enrollment/Waiver
  Student Health Insurance Enrollment/Waiver is an online process — paper forms are no longer available.
• Insurance Leave of Absence (PDF)
• Insurance Claim (PDF)

Medical Records

• Authorization for Treatment of a Minor (PDF)
• Notice of Privacy Practices
• Authorization for Release of Health Information (PDF)
• Authorization for Release of Medical Information and Confidential HIV-Related Information (NYC Department of Health mandated HIV-Related Information release form) (PDF)

Patient Accounts / Financial Services

• Application for Medical Emergency Funding (PDF) Available for Full-time Graduate and Professional students only