Forms

Please find the available forms below. A copy of a current picture identification, including signature (i.e. driver's license, passport) must be included with requests to release PHI or exchange PHI with parents/guardians.

A Consent Form for Medical Treatment of Minors (PDF)

Minor - Verification of Emancipation

Medical Exemption Policy for Required Vaccinations

Policy outlining the criteria and the process for exemptions to immunization requirements based on a medical condition

Medical Exemption Request Form

Form to be submitted for requesting a medical exemption for required vaccinations based on a medical condition

Religious/Personal Belief Exemption Policy and Request Form for Required Vaccines

Policy outlining criteria and process; form to be submitted for requesting an religious/personal belief exemption for required vaccinations

Medical Records Release Form

Authorization for Disclosure of Protected Health Information to Parents/Guardians

Notice of Privacy Practices (PDF)

This notice describes how medical information about you may be used and disclosed, and how you can get access to your information