Purdue University Student Health Center (PUSH)

Allergy & Immunization Clinic

Authorization to Use or Disclose Immunization Records (pdf)
Authorization to Use or Disclose Immunization Records (doc)
Authorization to Use or Disclose Yellow Fever Records (pdf)
Authorization to Use or Disclose Yellow Fever Records (doc)
Authorization to Use or Disclose Polio Records (pdf)
Authorization to Use or Disclose Polio Records (doc)

CAPS (Counseling and Psychological Services)

Authorization to Use or Disclose (pdf)
Authorization to Use or Disclose (doc)
Authorization for Use and Disclosure of PHI for Clinical or Educational Purposes (pdf)
Authorization for Use and Disclosure of PHI for Clinical or Educational Purposes (doc)

Nursing

Record of Disclosure, Chlamydia Report (pdf)
Record of Disclosure, Chlamydia Report (doc)
Record of Disclosure, TB Report (pdf)
Record of Disclosure, TB Report (doc)

Urgent Care

Record of Disclosure, Animal Bite Report (pdf)
Record of Disclosure, Animal Bite Report (doc)

Radiological and Environmental Management (REM)

Hepatitis B Authorizations: Immunization Letter to Supervisors (pdf)
Hepatitis B Authorizations: Authorization to Use or Disclose (pdf)
Hepatitis B Authorizations: Authorization to Use or Disclose (doc)

Student Services Workstation and Technology (SSWT)

Verification of Identity for Password Changes (pdf)