Health History and Immunization Forms
The State of Oregon and Oregon State University require the submission of a completed health history form and proof of 2 doses of MMR (measles, mumps, rubella). Students under the age of 22 must also provide documentation of one dose of meningococcal quadrivalent (MCV4) given within five years of the anticipated first day of OSU attendance. The preferred method for submitting the information is via the Patient Portal. If you are unable to use the Patient Portal you may print the form from the following link and fax it to Student Health Services at 541-737-9665.
Health History and Immunization Form (PDF)
International Student Health History and Immunization Form (PDF)
Assignment of Benefit and Release of Information for Insurance Billing
Complete this form to allow Student Health Services to bill your insurance and for SHS to receive any reimbursement payable for services and supplies that you receive at SHS. Students are responsible for all charges remaining after insurance reimbursement to SHS.
Assignment of Benefit and Release of Information for Insurance Billing (PDF)
Medical Record Release Form
You may receive a hard copy of your records, or you may have a copy forwarded to your personal health care provider, by completing the Authorization to Release Medical Information Form.
Authorization to Release Medical Information Form (PDF)
Request for Itemized Billing Statement
If you need a copy of your itemized billing statement, please complete this form and place it in any of the “Request for Itemized Billing” boxes conveniently located on the 2nd floor of the Student Health Center. Your billing statement will be mailed to you. This statement contains all the coding that is needed for your insurance company to process your claim. This bill will not reflect charges from the SHS Pharmacy (please request those statements directly from the Pharmacy).
Request for Itemized Billing Statement (PDF)
How to fill out the HCFA-1500 form you will receive (PDF)
Advance Directive Form
An advance directive is a set of instructions that explain the specific health care measures a person wants if he or she should have a terminal illness or injury and become incapable of indicating whether to continue curative and life-sustaining treatment, or to remove life support systems.
Advance Directive Form (PDF)
College of Veterinary Medicine Health History Form
Upon admission to OSU College of Veterinary Medicine, this form must be completed and submitted to receive medical clearance. This form is in addition to the general health history form you must complete before your first term at OSU, and is just one part of the required documentation for Veterinary Medicine students.
College of Veterinary Medicine Health History Form (Word doc)