Forms
Online Forms
For all areas of the health center
- HIPAA Acknowledgement Form*
- Insurance Information Form
- Medical Treatment Authorization Form
- Notice of Privacy Practices
- Authorization for Use and Disclosure of Protected Health Information Form
*The HIPAA 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 (PHI) by entities providing medical care and treatment.
Other forms
- HIV Risk Assessment Reaction Paper
- Asthma Progress Note
- Payroll Deduct (Express Pay) Enrollment Form
- Travel Consultation Form
- WMU Accident/Injury 311 Report Form
- #121 F/S Preventive History Form
- Medical Treatment for On-the-Job Injury Form (WC 210)
WMU Sports Medicine Clinic Forms
- PT Referral Form (for physicians)
- Sports Medicine Health History Form
- HIPAA Acknowledgement Form*
- Insurance Information Form
- Medical Treatment Authorization Form
- Notice of Privacy Practices
Adobe Acrobat Reader is required to view and print forms on this page.Release of Medical Records
How do I get a copy of my medical records?
If your home town 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 & 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 ten days notice is desired to allow time for copying and mailing. In addition, we recommend that, in most cases, the Health Center will mail your record directly to your physician. Authorization forms may also be obtained from the health care provider requesting your records.
Print the Authorization for Use & 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;
- or mail it to:
Health Information
Sindecuse Health Center
Western Michigan University
1903 W. Michigan Avenue
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 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.