Forms

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Authorization for Release of and/or Verbal Exchange of Medical Information Form

SHCS records are covered by the Family Educational Rights and Privacy Act (FERPA). Federal regulations state that university education records and treatment records are excluded from coverage under the HIPPA Privacy and Security Rules. Treatment records are records that are made or maintained by a healthcare professional; used only for your medical treatment; and are only available to treatment providers.

 

Students can make a written request to see their treatment records or release their records to entities outside of SHCS. However, when your records are disclosed to you they are considered education records (and are no longer treatment records). In this circumstance, the confidentiality protections under FERPA, though stringent, could allow further access to campus entities that are not a student's medical or mental health provider.

 

The consent to release treatment information is legally limited to circumstances that have already happened. Blanket consent can't be given in advance for circumstances that have not yet occurred. A patient may terminate a consent to release treatment records/information at any time. This must be done in writing. It is not possible for this to apply to records that have already been released as authorized.

 

SHCS will release medical information when requested in the following manner:

  • An Authorization for Release of and/or Verbal Exchange of Medical Information Form must be completed and signed by the patient for whom the records are requested.
  • The form must comply with the following:
    • Be accompanied by a photocopy of a current photo ID of the patient.
    • Include the patient’s full name, student ID, and the years wherein care was received from SHCS.
    • Include the address to which the records should be forwarded.
    • Include a current phone number whereby contact can be made with the patient.
    • Be signed by the patient.
  • If the records are to be released to a third party entity other than an individual, then a specific name, contact number and address of the receiving entity must be provided.
  • When requesting only limited information from the records, the time period and information to be released must be listed. We will release only the information requested.
  • You may submit your request by one of the following methods:
    • In person at SHCS,
    • By mail to:
      University of Tennessee at Martin
      Student Health and Counseling Services
      609 Lee Street
      Martin, TN 38238
    • By fax at 731-881-8852

Print an Authorization for Release of and/or Verbal Exchange of Medical Information Form

 

Consent for the Treatment of Minors

Except in a few instances (for example, treatment related to sexually transmitted diseases, drug or alcohol abuse, or emergencies), the State of Tennessee requires that a person be 18 years of age before he/she can receive medical treatment without the consent of a parent or guardian. It is often difficult to reach a parent or guardian to obtain consent each time that a student under 18 requires treatment, and it can be frustrating for the minor student awaiting treatment. Therefore, parents/guardians are given an opportunity to provide the information to facilitate treatment should a need arise by completing Consent for Treatment of Minors form.

 

Religious Vaccination Exemption Form

A student, or the student's parent or guardian if the student is a minor, provides to the university a written statement, affirmed under the penalties of perjury, that vaccinations conflict with his or her religious belief and practices.

 

Click here for the Religious Exemption Form

 

Notice of Information

Students are not required to provide documentation of vaccination against hepatitis b; but MUST acknowledge they have been informed of the risk factors and dangers by completing the Notice of Information.

 

Sexual Misconduct

Know what to do if you or someone you know is a victim of power-based personal violence.

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Suicide Prevention

If you have had thoughts of suicide, know that you are not alone. We are here to help.

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