Forms

If you have any questions regarding the forms (available on the right for download), please contact us.

Consent to Treat a Minor

This form is completed by a parent or guardian if student is less than 18 years of age.

Return the form by:

  • The student brings the form with him/her on the scheduled appointment.
  • Fax: 973-353 1390 (RUHS-Newark)

Notice of Privacy Policy

As required by the Health Insurance Portability and Accountability Act (HIPAA) of 1996, this notice describes how patient's health information may be used and disclosed and how a patient can get access to this information. Please read this carefully.

Consent to Release Medical Information to Patient

This form is completed and signed by the student. It gives Health Services consent to release the student's medical record to the student. Please provide all the necessary information (including contact information such as cell phone for verification or in case of a problem) so as not to delay the request. The medical record may then be released to the student.

If the student needs the medical record released to another person or facility, the student will have to 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:

  • Mail: Rutgers University-Newark Health Services, 249 University Ave., Blumenthal Hall Rm 104, Newark, NJ 07102
  • Fax: 973-353-1390
  • Visit us: 249 University Avenue, Blumenthal Hall Room 104, Newark, NJ 07103

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

  • Student picks it himself/herself (preferred)
  • Fax or Mail (understand this may not be secure)

There will be a service to fee of $0.50/page for the cost of copying associated with the request.