This form is required by Student Health Services. All students must have a completed form on file. This form must be completed by a healthcare provider and signed by the student or a guardian if the student is under the age of 18.
Information on meningococcal (meningitis) disease
Meningitis Fact Sheet
Release of information
SHS to another provider (use if sharing SHS records with parent, dean or provider)
Medical provider to SHS (use if sending records from home provider to SHS)
- Student Health Services strictly adheres to all state and federal regulations pertaining to confidentiality of medical records.
- A release of information form must be completed when a student makes any request for their patient information to be released to parent, family practitioner, referral doctors or anyone else.
- This form or a written request (must include DOB/School attended/specific information requested and where to send or Fax information/signed and dated) must be completed by an enrolled student requesting copies of his/her medical file.
- Copying charges may be applied and billed to your student account.
- The completed release form or written request may be mailed, faxed or hand delivered to Student Health Services and the request will be handled as promptly as possible.
- Fax requests for records by another physician must be accompanied by a signed request for release of medical records and will be sent at no charge, fax: (909) 621-8472.
- We do our very best to see that all requests are addressed promptly. However, during the summer break (June – August) it may take up to 15 business days to provide the information requested.
Mailing Address for forms sent to Student Health Services:
Student Health Services
757 College Way
Claremont, CA 91711
Fax: (909) 621-8472