HEALTH FORMS

All forms must be returned to the Decker Student Health Services Center unless otherwise noted.

Authorization for Release of Protected Health Information (8k pdf): Use this form to authorize Decker Student Health Services Center staff to release certain health information about you to the party you specify on the release. This isn’t a “blanket” release form; it must specify the illness or injury we may release information about and to whom this information may be given. See Confidentiality for more information.

Health Insurance Waiver Instructions: New domestic undergraduate students should submit an online waiver if they wish to waive automatic enrollment in the University’s health insurance plan. See Health Insurance for more information. THIS WAIVER MUST BE SUBMITTED THROUGH BU BRAIN TO THE STUDENT ACCOUNTS OFFICE BEFORE THE 6TH WEEK OF CLASSES OR YOU’LL BE RESPONSIBLE FOR THE COST OF THE INSURANCE.

International Student Insurance Claim (132k pdf): International students who carry the State University of New York plan through Binghamton’s International Student and Scholar Services office should use this form to make a claim.

Medical History Report New students should use the online medical history form found at https://myhealth.binghamton.edu to provide information about their health status to the Decker Student Health Services Center prior to registration. You will need your PODS username and password to log into this site. In the Education section of the home page is a link to complete immunization and health form submission instructions. See New Students for more information. COMPLETION OF THIS DOCUMENT IS A REQUIREMENT TO REGISTER FOR CLASSES AT BINGHAMTON UNIVERSITY.

Meningitis Information Acknowledgement: New students should use the immunization information form found at https://myhealth.binghamton.edu to indicate they have read and understand important information about meningitis from the New York State Department of Health (20k pdf). You will need your PODS username and password to log into this site. In the Education section of the home page is a link to complete immunization and health form submission instructions. See New Students for more information. COMPLETION OF THIS DOCUMENT IS A REQUIREMENT TO REGISTER FOR CLASSES AT BINGHAMTON UNIVERSITY.

Psychiatric Consultation Questionnaire (228k pdf): Students wishing to be seen for a psychiatric consultation should complete this form prior to their first visit. See Psychiatric Consultations for more information.

Attention Deficit Policy and Agreement (21k pdf): Students wishing to be seen for attention deficit disorder should read and sign this agreement form prior to their first visit.

Tuberculosis Screening Form: New students should use the online medical history form found at https://myhealth.binghamton.edu to provide information about their tuberculosis risk to the Decker Student Health Services Center prior to registration. You will need your PODS username and password to log into this site. In the Education section of the home page is a link to complete immunization and health form submission instructions. See New Students for more information. COMPLETION OF THIS DOCUMENT IS A REQUIREMENT TO REGISTER FOR CLASSES AT BINGHAMTON UNIVERSITY.

Under 18 Consent for Medical/Emergency Treatment (89k pdf): New students who are under age 18 must have their parent/guardian use this form to authorize Decker Student Health Services Center staff to provide medical or emergency treatment to the underage student. See New Students for more information. This document is also available in the Education section of the home page of https://myhealth.binghamton.edu. You will need your PODS username and password to log into this site.

Phone: 607-777-2221
Fax: 607-777-2881

Summer Hours

Last Updated: 10/27/14