Medical Policies and Forms

Please read this note to users sending or requesting forms with private health information (PHI) via email.

Policy Information Regarding:

• Medical Absence notes for missed classes/exams
• Prescriptions for ADHD medications
• Advanced directives and medical power of attorney

Policy Compliance with Assembly Bill 1278

• Assembly Bill (AB) 1278 requires physicians to provide a notice to patients regarding the Open Payments database which is managed by the U.S. Centers for Medicare and Medicaid Services, or CMS.  The Open Payments database is a federal tool used to search for payments made by drug and device companies to physicians and teaching hospitals. The federal Physicians Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.

Medical Forms

• Allergy Desensitization Information and Forms
• Medical Absence Form (Self Verification)

Health Information Management (Medical Records)

• Instructions: Requesting medical records
• Authorization for Disclosure of Health Information
• Authorization – Verbal Communication with Healthcare Provider
• 3rd Party Consent to Treat a Minor (required for students under age 18)
• Self Sufficient Minor Status Verification
• Request for Addendum for Clinical Notes

Health Insurance/Billing Forms

• Medical Claim Forms (Aetna)
• Billing Dispute Form (Student Health)
• Dental: Find updated claims information through the Delta Dental patient portal.
• Medical Claim Form for study abroad programs

Immunization Exemption Forms

For measles, mumps, varicella, meningococcal disease vaccines

• Medical Exemption for Immunization
• Religious Exemption for Immunization