Forms

Authorization to Release Medical Information Form(s)  - Individuals who would like to request copies of medical records from the Student Health Center, OR have staff request medical records be sent to the Student Health Center, must complete the appropriate form. All requests should include a copy of a photo ID (ie. Driver’s license or Student ID).

Please note electronic signatures are not accepted.

• Request Records from the Health Center be sent to another Medical Provider OR Patients can request a copy
  Please complete this form if you need the Health Information Management Staff to send your records to another provider; OR to request records be sent to you or to someone other than a medical provider.
• Request Records from Another Provider be sent to the Health Center
  Please complete this form(s) if you need the Health Information Management Staff to request your records from another provider in order to continue care at the Student Health Center.
• NOTE:  The SHC creates and receives Protected Health Information (PHI) for our patients and it may be disclosed electronically with patient authorization or when required by law. Electronic disclosures of PHI are sent securely using TXST approved encryption technology.

Parental Consent to Treatment for Minor - Please complete and sign all sections. Return to the Student Health Center by faxing to 512.245.9288, Attn: Medical Records or mail to the Texas State Student Health Center, Attn. Medical Records, 601 University Dr. San Marcos, TX 78666.