Forms/Medical Records

Registration & Consent for Treatment

The Registration & Consent Form becomes part of your confidential medical record, and can be completed online via the health portal. Please note that a parent's signature is also required if you are under 18 years old which requires you complete this form as well. It is helpful to have all necessary forms on file before you register, and will also prevent delays in your receiving medical care.

Consent information

Consent to the medical staff at HSU Student Medical Services for basic medical
examination and treatment. This includes lab and x­ ray tests, and any treatment
within the usual scope of care at a Primary Care clinic (including, but not limited
to procedures such as splinter removal, repair of lacerations, wart treatment, and
abscess drainage), when deemed advisable by, and rendered under the general
supervision, of a physician licensed under the provisions of the California Medical
Practice Act. Understand that treatment will be kept confidential under current State
and Federal medical privacy laws or by subpoena or required morbidity and mortality reporting.


Medical Record Release

Please complete the Medical Record Release Form if you have medical records you want transferred between the Student Health Center and another healthcare facility. The release of records becomes part of your confidential medical record. Please note that a parent's signature is also required if you are under 18 years old. If you are scheduling an appointment at the Student Health Center for a condition which has been treated at another healthcare facility, please have these records sent to the Student Health Center prior to your visit.

Student “Excuse” Policy

Students are often required to confirm illness, injury, or disability for various academic and/or employment-related reasons. We can provide such confirmation, as long as certain conditions are met (listed below). In view of the fact that the SHC has a high demand for services, we are interested in doing so with as little expenditure of staff (and student) time as possible, while still maintaining our honesty, integrity, and accuracy.

More information on Student “Excuse” Policy:

Some situations in which confirmations are requested include the following:

• Student was busy at SHC, and missed class or activity because of it;
• Student missed classes or activity because of injury or illness;
• Student cannot participate in class or activity due to injury or illness;
• Student is unable to continue with class or classes due to injury or illness, needs to drop out for medical reasons;
• Student needs to withdraw from HSU (completely or temporarily) due to injury or illness.


Conditions for our confirming illness, injury, or disability:

• SHC providers and/or staff must have been involved in care of condition, or can confirm via outside medical records that the injury or illness occurred, including instructions for return to full activity. The health center staff cannot confirm anything in writing that cannot be confirmed via medical records or direct experience.
• Written or verbal permission must be given by the student to provide specific medical information to others, as required by Federal law.
• In instances where a student was initially seen in the health center for a health problem which did not improve, the student must have returned for a repeat visit, or have informed the health center staff that they have not improved. Failure to apprise health center staff in a timely fashion of continued problems may lead to denial of retroactive request.
• PLEASE NOTE we CANNOT confirm permanent or extended disability for State or other Disability Insurance, nor can we do evaluations or fill out forms for these purposes.

Much of the time, written confirmation can be obtained at the time of a visit, or after the visit, without having to make a separate appointment with a provider. Please call the SHC at 707 826-3146, or come to the Health Center reception window during regular hours for assistance. 


Withdrawal from One or More Classes Due to Illness Or Injury

Clinic policy requires that you have been established and treated for the condition at the Student Health Center. Please make an appointment to see the provider who has seen you for this condition. If another health care provider has been seeing you off campus, please contact that office to request verification of illness. Please make sure you follow the instructions for withdrawal from the Office of the Registrar.

Compliment/Complaint Process

We value and appreciate your feedback about the Student Health Center. Please send comments, concerns, or compliments to via email or use our Contact form, or call us at (707) 826-3146. White suggestion forms are also available in our facility with a private drop-box just inside our front entrance. We are always looking for ways to improve and would love to hear from you!

Advance Directives

The Student Health Center recognizes that adults should consider “end of life” decisions and make responsible arrangements for this purpose. Resources to assist young adults in making these choices have been provided below.

Frequently Asked Questions about Forms/Medical Records

What health center forms do I need to complete before starting at HSU?

To prevent delays in receiving medical care and to avoid a hold on your registration, please complete the following forms:
1. The Registration & Consent Form 
2. Complete the immunization form through the Secure Message Portal AND fax or mail a copy of your immunization record to the Student Health Center.
3. Complete the Medical Record Release Form if you have medical records to transfer from another healthcare facility to the Student Health Center.


Are there any limits to confidentiality at the Student Health Center?

Yes, there are a few permitted or required by law. Our medical staff are “mandated reporters” and are required by law to report injuries caused by weapons, possible sexual assault, domestic or child abuse, or if you are in danger of injuring yourself or others. If you wish to discuss your situation with someone who is not a “mandated reporter”, we can connect you with certain staff members who have no mandated reporting requirement. Also, if a clinician feels that your health or safety, or those of others, are immediately at risk, they may consult anyone who may be of help, including police, with or without your permission.


When will Emergency Contacts be called?

Emergency Contacts will be called when Student Health Center staff become aware that the student is experiencing a major medical or psychiatric emergency; one in which their life, safety or long term health appear to be at risk. They may also be contacted as explained above, even without the student’s permission, if the student’s situation puts themselves or others in dire risk. However, they will be contacted for less dangerous or severe medical or psychiatric problems only at the student’s request.


Can parents or guardians gain access to information about students’ health problems or care at the Student Health Center?

Since the vast majority of students are 18 or older, they have legal status as adults, and therefore under Federal law have control over what medical information about them can be released to whom. Thus, documented consent from the student is necessary for any information to be released to anyone, including parents and guardians, with a few exceptions as discussed above. We will certainly be willing to listen to parents’ concerns, but what we can tell you is quite limited without a student’s permission. For students under the age of 18, parents or guardians may request and receive information, though information about birth control, pregnancy, treatment of sexually transmitted diseases cannot be discussed even with parents under California state laws, without the student’s documented permission. Such permission can be given in writing or verbally to Health Center staff. In instances of sexual assault or psychiatric problems, parents will not be contacted if the treating clinician determines that it would harm the student to do so.


What is the Secure Message Portal and just how “secure” is it?

The Secure Message Portal is a feature of our computerized Medical Record System, which allows us to communicate with patients in a medically confidential fashion, as required by Federal law. It is password-protected to maintain this confidentiality. Not only can messages be sent, but copies of lab reports and important forms reside in the Secure Message Portal. Don’t share your password with anybody, unless you’re OK about them seeing your confidential info!