Forms and Documents
On this page, you will find useful forms and documents relating to health care at the Klotz Student Health Center.
NEW PATIENT FORMS
Students can access and complete new patient forms including: SHC Acknowledgement of Fees, SHC Health History, SHC Notice of Privacy Practices and SHC Treatment Agreement through the myhealth patient portal.
For students who are under 18 years old and would like to receive care at the Student Health Center, please complete the following form:
Consent for Treatment of Minors
CURRENT RELEASE OF INFORMATION GUIDELINES
To request a copy of your medical records, please submit a completed “General Consent to Disclose/Release of Information” form (found below) with a copy of your photo ID.
The completed form can be submitted by:
- Visiting the Klotz Student Health Center during Release of Information operating hours:
- Monday, Tuesday, Wednesday, and Friday from 8:30 am to 11:30 am and 1:30 pm to 4:30 pm
- Thursday from 9:30 am to 11:30 am and 1:30 pm to 4:30 pm
- Faxing the completed form to (818) 677-2304
- Mailing the completed form to: 18111 Nordhoff Street, Northridge, CA 91330-8270
Please allow 3 to 5 business days for processing. For any questions or additional help, please call us at (818) 677-3666, Option 1.
Please Note: We do not release medical records through email.
General Consent to Disclose/Release of Information
ACADEMIC WITHDRAWALS FOR MEDICAL REASONS
Medical withdrawals from the university are taken on a case-by-case basis. To ensure your medical withdrawal processes correctly, please contact the appropriate campus staff.
Undergraduate students
If you need to withdraw from classes for a medical reason, please contact the Office of Undergraduate Studies in University Hall 215 or call (818) 677-2969.
Graduate students
If you need to withdraw from classes for a medical reason, please contact the Office of Graduate Studies at (818) 677-2138.