Clinic Forms

Request a Copy of Your Health Record

You may use the request form Authorization for Release of Health Information (PDF) for a printable copy. All information must be completed in order for your request to be processed. Please complete and return the Consent to Release or Receive Medical Information (PDF) form

* Please allow 48-72 hours from receipt of a signed release for your health information records to be processed.

Request a Copy of Your Mental Health Record

You may use the request form Authorization for Release of Health Information (PDF) for a printable copy. All information must be completed in order for your request to be processed. Please complete and return the
Consent to Release or Receive Mental Health Information (PDF) form

* Please allow 48-72 hours from receipt of a signed release for your health information records to be processed.

Health Insurance Information Form

You may provide health insurance information to the Student Health Clinic prior to an appointment or if your insurance has changed. Please complete the Insurance Information Form and return along with a copy of your insurance card (front and back). Students: If you are 18 or older make sure you sign the form.

Treatment of Minors

For students under 18 years of age, a parental or legal guardian authorization for medical treatment form must be on file in our office in order for you to receive prompt care and treatment, should the need arise. Please complete and return the Consent for Treatment of a Minor (PDF) form

Mandatory Health Requirements

Immunization to measles, mumps, and rubella (MMR) is a requirement for all students who attend UNI. To comply with this requirement all students must provide records documenting proof of TWO measles, mumps, and rubella(MMR) vaccinations. Immunization dates must include month, day and year. We also must collect information on the status of student's vaccinations against meningococcal disease. Students can provide both the MMR and Meningitis vaccine on the UNI Health Requirement Immunization Verification Form. (pdf) A photocopy of your immunization record should be attached to the Health Requirement Immunization Verification form.

All Clinic forms can be emailed to: healthcenter@uni.edu