HealthMARIST COLLEGE
3399 North Road, Poughkeepsie, NY 12601
Services
845-575-3270/845-575-3275 fax
AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION
Dear Incoming Freshman Student,
1. I authorize
___ Marist Health Services
OR
___ Other: ____________________________________
____________________________________
Congratulations on your acceptance to Marist College!
2. To disclose
the protected
health
information
of of the Student Center, provides care to all full-time undergraduate
Marist Health
Services,
located
in Room 350
students. The office is staffed by physicians, nurse practitioners, physician assistants, nurses and clerical staff.
Name _______________________________ CWID_____________________
Date of birth ______________
After hours or in emergencies, students are referred to the Emergency Department of Saint Francis Hospital,
Address
_________________________________ CITY _____________________
STATE ___________________
which is across the street from the Marist College campus.
__________________________________ ZIP CODE _________________ PHONE___________________
Enclosed are Marist Health Services forms which must be completed and signed. You should schedule a visit
with
your primary
care or
provider
so that all forms can be received at Marist College as soon as possible after
3. To the
following
individual
organization:
enrollment,
by
July
30
for
incoming
Fall students. (If you are unable to schedule your physical exam in time for
Name_____________________________________________________________________________________
the deadline, please submit all other forms and note “physical exam to follow” with the date. If you have had a
Address___________________________________________________________________________________
complete physical since September 2009 that is documented on a similar form, you may submit it for review.)
Phone __________________________________
Fax __________________________________
If you choose, you may include page 10, “Consent to discuss medical information for students 18 and older,” so
4. Purpose of the disclosure:
staff can discuss confidential health information with your parents or guardians.
___ further health care
___ insurance documentation ___ legal investigation
___ academic
accommodation
___and
personal
usewho may want to___
of services
Marist College
varsity athletes
students
try coordination
out for a varsity
team should not complete this
packet_________________________________________________________________________________’
of forms. They must complete and send “Incoming Athlete Medical Forms” to the Marist College Office
___ other
of Athletic Training by July 15 for Fall semester. A copy of all forms must also be sent to the Office of Health
5. Information
to be
disclosed
Services.
Incoming
Athlete Medical Forms are available at www.marist.edu/healthservices/healthforms.
Incoming immunization record only
We strongly
recommend that you keep a copy of all health forms for your own reference. It takes our staff most
Treatment
dates___________________________________________________________________________
of
the
summer
and
review the many
incoming forms. Please do not phone to see if
___ clinical notes to process
___ lab
reports
___hundreds
radiology of
reports
your forms have arrived. If you need to know that your forms were received, please send them “return
receipt
requested” via US mail and you will receive confirmation by return mail.
___ other
________________________________________________________________________________
6.
7.
Studentsthat
will not be allowed to move into campus housing or register for classes unless proof of
I understand
immunization
has
received at
(see
a.
I may revoke
thisbeen
authorization
anypage
time. 2).
The revocation will not apply to information that has already been
released in response to this authorization. I must revoke this authorization in writing.
We Information
look forward
to working
with you
to authorization
ensure a healthy
Marist
experience.
b.
disclosed
pursuant
to this
may be
subject
to redisclosure by the recipient of such
information. It is possible that, once disclosed, the privacy of the information may no longer be protected under
Sincerely,
federal medical privacy law.
c. Unless otherwise revoked, this authorization will expire on (date or event)_______________________. If I fail to
specify
an expiration
date or event, this authorization will expire one (1) year from the date of my signature.
Mary
L. Dunne,
MD
I haveMedical
read and
understand the information in this authorization form.
Director
page 2
Medical History / Emergency Contact / Health Insurance information
SignatureEnc:
______________________________________________________________
Date _____________________
page 3
Measles, Mumps, and Rubella (MMR) Vaccination Information
page 4
Mandatory Meningitis Information
page 5
Marist College Mandatory Immunization Information
Witness ______________________________________________________________
Date _____________________
page 6
Physical Examination Form - to be completed by Health Care Provider
page 7
Copy of front of insurance card
page 8sign forCopy
back ofother
insurance
Director/Dean must
any ofrelease
thancard
immunization records _________________________________________
page 9
Medical Authorization and Consent form
Action to be taken
___ to
copy
andmedical
mail ___
oral/phone
discloseover
only
page 10___ fax
Consent
discuss
information
(for students
18)___ obtain records indicated above
Records were
___ discussed ___ faxed ___ mailed ___ picked up on _______________ Initials _________________
Record request was ___ discussed ___ faxed ___ mailed ___ picked up on _______________ Initials _________________
Office of Health Services
Marist College, Poughkeepsie, NY 12601-1387
845-575-3270 - health.services@Marist.edu
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