Forms

Immunizations

• Immunization Documentation Form (optional - not required)
• Immunization Exemption Request Form (online form)

Insurance

• DO NOT File Insurance Form

Medical Records/Consent

• Authorization for Disclosure of Protected Health Information (verbal disclosure)
  This form is used to provide verbal disclosure to a patient's protected health information to another individual, such as a parent and/or guardian.
• Authorization to Release Medical Information (physical records request)
  This form is used for patients requesting their physical records be sent and/or shared with themselves, another individual or a facility. There may be a charge to have records copied.
• Authorization to Release Medical/Health Related Information (NDSU internal form)
  This is an online form used with internal NDSU departments that include Student Health Service, Center for Accessibility and Disability Resources, Counseling Center and Dean of Students (Case Management).
  This form must be initiated by a Student Health Service staff member.
• Consent to Treat a Minor Child or Adult with Guardianship (Parent/Guardian Authorization)
  This form is used for students who are under the age of 18 or adults with legal guardianship and parent/guardian permission is required before care can be provided.

Advance Directive

• Create a Health Care Directive
• Another good resource would be your state's Department of Health website

Class Excuse Documentation

• Student Health Service can provide class excuse letters to students by request.
• An email was sent to campus from Dean of Students on 8/11/2025 stating that instructors should be flexible with students regarding class absence. A copy of that email can be found by clicking here. Please refer to NDSU's Policy Manual, specifically Section 333 - Class Attendance Policy and Procedure.