Forms

Advance Directives

Advance directives are legal documents that allow you to decide in advance what type of medical care you would desire if you are ever unable to speak for yourself. These documents ensure that you get the care you want should an unexpected serious illness or accident occur. In addition, these documents minimize the stress of people who will need to make decisions on your behalf if you are unable to do so.

Student Health encourages everyone to have an advanced directive. We will assist you in completing your advance directive and will place a copy in your medical records. In addition, you will need to fill out the Advance Directives for a Natural Death form with the State of North Carolina.


Allergy Immunotherapy

Letter to Physician [PDF]

This form is for new patients of the Student Health Services Allergy Immunotherapy Clinic. Before your first appointment, your allergist must complete this form. Bring the completed form, your allergist’s papers and your serum with you to your first allergy appointment at the Student Health Center.

Physician Order for Allergy Immunotherapy_Jan_17_2017 [PDF]

This form is for new patients of the Student Health Services Allergy and Immunotherapy Clinic. Before your first appointment at the Student Health Services Allergy Clinic, your allergist must complete this form. Bring the completed form, your allergist’s papers and your serum with you to your first allergy appointment at the Student Health Center.


Health Records

Authorization to Release Protected Health Information [PDF]
If you would like to give written permission for the release of your medical records to others, complete this form and attach a copy of a picture ID.

Health History Form 
If you are new to NC State, log in to HealthyPackPortal to complete this form online. Click Forms tab at the top of the page. Click Health History Form. Please answer the questions honestly and to the best of your knowledge.

NC State Immunization Record Form [PDF]
The Immunization Record Form is designed to collect information about your current immunization status. If you do not have a personal immunization record, the form below can be used in place of your personal immunization record. The record must have a medical provider’s name and address or clinic stamp with provider name and address. You should make and keep a copy of your form for future reference. Please do not submit originals. Please complete and return this form BEFORE you arrive on campus. North Carolina public law requires that you submit proof of your immunizations to the Student Health Center within 30 days of your acceptance at NC State University. The North Carolina Department of Health and Human Services answers questions about college and university immunization requirements.

Medical Exemption Forms
The Commission for Health Services shall adopt by rule medical contraindications to immunizations required by G.S. 130A-152. If a physician licensed to practice medicine in this State certifies that a required immunization is or may be detrimental to a person’s health due to the presence of one of the contraindications adopted by the Commission, the person is not required to receive the specified immunization as long as the contraindication persists. The State Health Director may, upon request by a physician licensed to practice medicine in this State, grant a medical exemption to a required immunization for a contraindication not on the list adopted by the Commission.

Notice of Privacy Practices [PDF]
This document describes how your medical information may be used and/or disclosed, and how you can access your medical information.

Parental/Guardian Consent for Treatment of a Minor Form [PDF]
This form is for parents/guardians whose students are under age 18. Complete this form in order to authorize Student Health Services to provide medical services for students under 18.

Summer Camp Consent [PDF]
This form is for use by the parents/guardians of minors attending camp activities on campus. University departments and/or camp organizers may download this form to share with parents/guardians or direct them to this site to download the form.


Insurance

University-sponsored Health Insurance Plan Waiver Form [online form]
If you wish to waive university-sponsored Health Insurance Plan, then complete the online form on Student Blue’s website.

University-sponsored Health Insurance Plan Enrollment Form [online form]
If you wish to enroll in University-sponsored Health Insurance Plan, then complete the online form on Student Blue’s website.

University-sponsored Mandatory & Voluntary Health Insurance Plan Benefits [PDF]
This includes all of the information regarding the benefits and exclusions for the school policy.


Occupational Medicine

Occupational Medicine Exam Request Form & Authorization for Release of Medical Information
This form is for university employees and students whose jobs either require or recommend medical surveillance.


Pharmacy

If you know your prescription number, request refills via the mobileRX app (for Android or iPhone) or online.

If you do not know your prescription number, request refills in person or by phone at 919.515.5040.


Travel

Faculty and Staff Occupational Medicine Exam Request Form
Faculty and staff must complete this form before work-related travel so their departments can be billed for associated fees.

Students, please register online with the travel clinic 6-8 weeks before you plan to travel. For more information about appointments and travel, visit the Travel Clinic page.


Worker’s Compensation

Worker’s Compensation Form [PDF]
If you are an NC State student worker who has suffered a job related injury, have your employer complete this form. Bring the form to your scheduled appointment at the Student Health Center. Read more about worker’s compensation at NC State University.