Forms
Please include this note to users sending or requesting forms with private health information (PHI) via email. All forms can be submitted online but must be printed and signed in ink.
Review the sections below to find the form you are looking for today!
Student Health does not provide routine written medical excuses for short-term absences from class or missed deadlines due to illness or injury. This practice policy is recommended by health services staff and approved by the Student Health Advisory Committee, the Office of the Vice President for Student Life, and the Office of the Provost.
Part of the mission of Student Health is to teach appropriate healthcare consumerism. The practice of providing medical excuses seems to send mixed messages to students about the appropriate use of healthcare resources.
Information on steps to take regarding an absence from class can be found on the Registrar's website.
An additional resource for you is to sign up for MyChart. MyChart contains your medical record and other health related information. MyChart allows you to print documentation of your visit to Student Health, or other University of Iowa medical clinics. You are not required to disclose any private information about your visit.
Please contact us if you have further questions or require assistance.
- Insurance Form - Information we need to bill any Student Health charges to your insurance. (Can send in advance, or student will complete at first visit)
- HIPAA Privacy Notice Form
- A&A - Authorization to Bill and Authorization to Release of Information
Submit ONLY if you are requesting an exemption to the UI immunization requirement, because of a medical condition or religious belief. Students aged 18 and over must complete and sign their own religious exemption form, including having it notarized.
Iowa Department of Public Health Exemption form
Iowa Department of Public Health Religious Exemption form
If you have an official, valid religious or medical exemption form (must be current, not from childhood, signed by the student if over age 18), do not submit this through Med+Proctor, as they will not process it. Email your official form to [email protected].
Consent to Obtain Information Form (not required - only needed if you want a healthcare provider to send Student Health your medical record history. Generally no form is needed to request your immunizations from your provider- just call and have them fax/send or use a patient portal)
- Consent to Release of Information form
- Instructions for Release of Information (not required - only needed if you want Student Health to release your protected health information to another entity)