Forms

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Student Health Services Forms

Allergy Immunotherapy

Letter to Physician [downloadable PDF]
This form is for new patients of the Student Health Services Allergy Immunotherapy Clinic. Before your first appointment, your allergist must complete this form. Bring the completed form, your allergist’s papers and your serum with you to your first allergy appointment at the Student Health Center.

Physician Order for Allergy Immunotherapy [downloadable PDF]
This form is for new patients of the Student Health Services Allergy and Immunotherapy Clinic. Before your first appointment at the Student Health Services Allergy Clinic, your allergist must complete this form. Bring the completed form, your allergist’s papers and your serum with you to your first allergy appointment at the Student Health Center.

Insurance
University-sponsored Health Insurance Plan Waiver Form [online form] If you wish to waive University-sponsored Health Insurance Plan, then complete the online form on Student Blue’s website.

University-sponsored Health Insurance Plan Enrollment Form [online form] If you wish to enroll in University-sponsored Health Insurance Plan, then complete the online form on Student Blue’s website.

University-sponsored Mandatory & Voluntary Health Insurance Plan Benefits [printable PDF] This includes all of the information regarding the benefits and exclusions for the school policy.

Medical Recordkeeping
Authorization to Release Protected Health Information [downloadable PDF] If you would like to give written permission for the release of your medical records to others, complete this form and attach a copy of a picture ID.

Health History Form [online form] If you are new to NC State, log in to HealthWeb to complete this form online. Click Forms on the left. Scroll down to the list at the bottom of the page. Click Health History Form. Please answer the questions honestly and to the best of your knowledge.

Immunizations Form [downloadable PDF] All students must submit proof of immunization forms BOTH online AND in paper form within 30 days of their acceptance to NC State University. To enter immunization information online, log in to HealthWeb. Click Forms. Scroll down to the list at the bottom of the page. Click Immunizations Page. Fill out the form. Click Proceed. Print this page and enter unofficial dates of your immunizations from sources such as baby books or your mother’s personal records (these records may not have doctor’s signatures.) Then take the form to your doctor for a signature to make the dates official. Once a doctor has signed your verification form, submit it to the NC State University Immunizations Compliance Office.

Medical Exemption Statement [downloadable PDF] Health care providers complete this form when a patient has known contraindication to receiving additional vaccination.

Notice of Privacy Practices [downloadable PDF] This document describes how your medical information may be used and/or disclosed, and how you can access your medical information.

Parental Consent for Treatment of Student Under 18 Years Old [downloadable PDF] This form is for parents whose students are under age 18. Complete this form in order to authorize Student Health Services to provide medical services for students under 18.

Physician’s Request for Medical Exemption [downloadable PDF] This form is for health care providers to request an exemption for an immunization not specified in North Carolina Administrative Code (10 NCAC 41A.0404) as a valid contraindication to immunizations.

Summer Camp Consent [downloadable PDF] This form is for use by the parents/guardians of minors attending camp activities on campus.  University departments and/or camp organizers may download this form to share with  parents/guardians or direct them to this site to download the form.

Occupational Medicine
Occupational Medicine Exam Request Form & Authorization for Release of Medical Information [downloadable PDF]
This form is for university employees and students whose jobs either require or recommend medical surveillance.

Pharmacy
Pharmacy Self-Care Item Request Form [downloadable PDF] Print and complete this form. Present the form and your student ID card in person at the Student Health Center Pharmacy in order to obtain self-care pharmacy items.

Pharmacy Online Refill Request Form [online form] To request prescription refills online, first log in to HealthWeb. Verify your date of birth. Click Messages at left. Then click New Message. Click the button next to NCSU Pharmacy-questions and refills. Click Continue. Click Refill Request. Click Continue. Enter the name of your medication, prescription number, number of refills you need, and a contact phone number. Click Send. You will not receive a confirmation email. Please allow us two business hours to refill your prescription, and then come to the Pharmacy to retrieve your refill. If there is a problem with your request, we will call you at the number that you provide on your refill request form.

Travel
Exam Request Form & Authorization for Release of Medical Information for Faculty [downloadable DOC].  Faculty and staff must complete this form before work-related travel so their departments can be billed for associated fees.

Worker’s Compensation
Worker’s Compensation Form

If you are an NC State student worker who has suffered a job related injury, have your employer complete this form. Bring the form to your scheduled appointment at the Student Health Center. Read more about worker’s compensation at NC State University.

Counseling Center Forms

Rights and Responsibilities Form
This document summarizes important information that you should know about our services.  You will be asked to read, sign and date an electronic copy of this form when you are first seen at the Counseling Center and this copy serves as one you can refer to if needed.

Notice of Privacy Practices
This document describes how your counseling information may be used and/or disclosed, and how you can access your counseling information.

Withdrawal Request Information Sheet
Read these instructions carefully before you complete the pre-application for a withdrawal request.

Early Withdrawal Application for Degree Students
Use this form to apply for a withdrawal that will be submitted before the last day to withdraw without a grade.

Late Withdrawal Application for Degree Students
Use this form to apply for a withdrawal that will be submitted after the last day to withdraw without a grade.

Authorization for Release of Counseling Center Records
This form is for individuals who want to give written authorization for the release of their Counseling Center records to others.

Health Provider Letter
This letter is for medical providers to make a recommendation about a student’s academic withdrawal.

Appeal for No-Show Appointment
If you believe that we charged you in error for a no-show or late cancellation please complete this form and return it to the Counseling Center

Application for Training
Prospective interns and practicum students should complete this application form as part of their application processes.