Forms and Documents

On this page, you will find useful forms and documents relating to health care at the Klotz Student Health Center.

NEW PATIENT FORMS

Students can access and complete new patient forms including: SHC Acknowledgement of Fees, SHC Health History, SHC Notice of Privacy Practices and SHC Treatment Agreement though the myhealth patient portal.

For students who are under 18 years old and would like to receive care at the Student Health Center, please complete the following form:

Consent for Treatment of Minors

CURRENT RELEASE OF INFORMATION GUIDELINES

If you are requesting a copy of your medical records, please submit your completed "General Consent to Disclose/ Release of Information" form (found below) with a copy of your photo ID to immunization@csun.edu. Due to limited staffing, please allow up to 7 to 10 business days for processing. For urgent requests, please call us at (818) 677-3666, Option 1. Please note, we do not release medical records via email.

General Consent to Disclose/Release of Information

ACADEMIC WITHDRAWALS FOR MEDICAL REASONS 

Medical withdrawals from the university are taken on a case-by-case basis. To ensure your medical withdrawal processes correctly, please contact the appropriate campus staff.

Undergraduate students

If you need to withdraw from classes for a medical reason, please contact the Office of Undergraduate Studies in University Hall 215 or call (818) 677-2969.

Graduate students

If you need to withdraw from classes for a medical reason, please contact the Office of Graduate Studies at (818) 677-2138.