Student Health Services Forms

Consent to Treat a Minor

If you are under the age of 18, please have your parent or guardian complete this form. Bring the signed form with you when you come to your scheduled appointment.

Consent to Treat Minor Form

Consent to Release Medical Information

Your privacy is important to us. We will not release your medical records without your permission. If you would like your records released to you, complete and sign this HIPAA release form. It gives Student Health Services permission to release your medical records. Please provide all the necessary information (including the best contact information to reach you). Once we have the signed form, we can can release your records.

If you need your medical records to be released to another person or facility, please contact Health Services at (973) 353-5231. This would require a different consent form as required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to protect the student's privacy.

Return the form by:

• Fax: (973) 353-1390

• Mail: Rutgers University-Newark Health Services, 249 University Ave., Blumenthal Hall Rm 104, Newark, NJ 07102
• Visiting us: 249 University Avenue, Blumenthal Hall Room 104, Newark, NJ 07102

Copy of the medical record can be released to the student by:

• Pick up the medical record at Blumenthal 104 (preferred)
• Fax or Postal Mail (understand this may not be secure)

Consent to Release Medication Information Form