For all areas of Sindecuse Health Center
If you are unable to view these forms, download and install Adobe Reader.
- HIPAA Acknowledgement - for receipt of notice of privacy practices*
- Insurance Information
- Medical Treatment Authorization
- Notice of Privacy Practices
- Authorization for Use and Disclosure of Protected Health Information
*The Health Insurance Portability and Accountability Act Privacy Rules (federal regulations that became effective April 14, 2003) provide important protection for health information including that your authorization is obtained in certain circumstances. The Privacy Rules apply to the use and disclosure of Protected Health Information by entities providing medical care and treatment.
- HIV Risk Assessment Reaction Paper
- Asthma Progress Note
- Payroll Deduct (Express Pay) Enrollment
- Travel Consultation
- WMU Accident/Injury 311 Report
- F/S Preventive History 121
- Medical Treatment for On-the-Job Injury WC 210
WMU Sports Medicine Clinic forms
Release of medical records
How do I get a copy of my medical records?
If your hometown physician or a medical specialist requests a copy of your Sindecuse Health Center medical record, you must sign an authorization before we can send it. Information from your medical record is never shared with any area of the University, or with any administrator, faculty or staff member without your written consent.
Sindecuse Health Center has an Authorization for Use and Disclosure of Protected Health Information form which you must sign and date. This form asks you to identify the physician or medical office requesting the records. Seven to 10 days notice is desired to allow time for copying and mailing. Authorization forms may also be obtained from the health care provider requesting your records.
Print the Authorization for Use and Disclosure of Protected Health Information form and fill it out completely according to the instructions below.
- Bring the signed authorization and a picture ID to Sindecuse Health Center
- Fax it to (269) 387-4494, Attn: Medical Records
- Mail it to:
Sindecuse Health Center
Western Michigan University
1903 W Michigan Ave
Kalamazoo MI 49008-5445
How do I complete the authorization form?
- Fill in all identification information on the top four lines.
- Circle "From" or "To" Sindecuse Health Center depending upon whether we are sending your information somewhere or requesting it from another provider.
- Circle "From" or "To" another person or organization.
- Fill in the complete address of the provider or organization where we will be sending your information or from whom we will request your information.
- Put a check in the box beside the parts of the medical record you want sent or requested. If you are not sure of what reports should be checked, please contact us.
- Put a check in the box regarding the purpose for this request.
This authorization is good for one year. You may change this time by filling in another date or event (i.e. graduation from WMU). If you are 18 or older, be sure to sign and date the form. If you are under 18, a parent or guardian must sign and date the form and list the relationship to the patient.
Where can I get more information about my records?
You can call us at (269) 387-3286 or (269) 387-3290.