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 Humboldt 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

Humboldt's Health and Counseling Centers do not generally provide medical excuse notes. The vast majority of legitimate excuses for missing classes, exams athletic training or events, or work (such as colds, headaches, nausea, vomiting, diarrhea, abdominal pain, dizziness, etc.) do not lend themselves to objective confirmation, especially after the fact. Most of these conditions require self-care, not an office visit. We have provided an Absence Form for self-verification of an illness that is not required but can be helpful to begin a dialogue with your instructor. We also include a note for your professor, coach, or work supervisor explaining that the reasons many campuses such as ours do not provide excuse notes. If you have an ongoing condition that requires accommodation, including a withdrawl, you will wish to begin by speaking immediately and directly with The Student Disability Resource Center. Our health providers are also unable to provide documentation required after-the-fact for retroactive withdrawals if you have not been working with them previously. 

At Student Health & Wellbeing Services we believe that these policies support the philosophical and educational foundation of higher education; namely to model and nurture honesty, integrity, and citizenship in emerging adults. Students are expected to be honest with their professors regarding their ability to complete work, and professors should work with students on these issues while upholding the integrity of the learning environment for everyone.

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.

Frequently Asked Questions about Forms/Medical Records

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

To prevent delays in receiving medical care and to avoid a hold on your registration, please complete the following forms:

1.  Complete the immunization form through the Secure Message Portal AND fax or mail a copy of your immunization record to the Student Health Center.
2.  Complete the Registration & Consent Form online via the health portal 


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!