Students Health Center Forms

Forms and Documents

Entrance Physical

This form is required by Student Health Services. All students must have a completed form on file. This form must be completed by a healthcare provider and signed by the student or guardian if the student is under the age of 18.

Information on meningococcal disease

Release of Information forms

  • Student Health Services strictly adheres to all state and federal regulations pertaining to confidentiality of medical records.
  • A release of information form must be completed when a student makes any request for their patient information to be released to parent, family practitioner, referral doctors or anyone else.
  • This form or a written request (must include DOB/School attended/specific information requested and where to send or Fax information/signed and dated) must be completed by an enrolled student requesting copies of his/her medical file.
  • Copying charges may be applied and billed to your student account.
  • The completed release form or written request may be mailed, faxed or hand delivered to Student Health Services and the request will be handled as promptly as possible.
  • Fax requests for records by another physician must be accompanied by a signed request for release of medical records and will be sent at no charge, fax: (909) 621-8472.
  • We do our very best to see that all requests are addressed promptly. However, during the summer break (June – August) it may take up to 15 business days to provide the information requested.

Mailing Address for forms sent to Student Health Services:

  • Student Health Services
  • Medical Records
  • 757 College Way
  • Claremont, CA 91711

Or email to: shsrecords@cuc.claremont.edu

image of cuc
Sign into My Health Portal Please Give Us Your Feedback!

Go to

Contact us

Phone 909-621-8222
Fax 909-621-8472
After Hours Emergency 909-607-2000
E-mail SHS records
Address
  • Tranquada Student Services Center, 1st floor
  • 757 College Way
  • Claremont, CA 91711

Other Resources

Student Health Insurance

See also

Last updated: 1/20/2017 6:12:39 PM