Forms
The following files are in PDF format. A free PDF reader, Adobe Acrobat, is available for download.
- Health Report
- Application for the Learning Disabilities Program
- Release of Medical Records form
- Meningitis Waiver
Medical Leave of Absence
A Medical Leave of Absence (MLOA) is an option to consider when a student is diagnosed with a major medical illness, injury, or psychiatric illness, after the start of the term that significantly interferes with his or her ability to attend classes and complete requirements.
Medical leave requests must be initiated through University Health and Counseling Services by sending a completed request form and documentation from a clinician supporting the medical leave.
Re-entry from a medical leave requires a completed request for re-entry form and clinical documentation supporting the re-entry to classes be faxed, sent, or delivered to UHCS on or around one month prior to the planned re-entry. Clinical documentation supporting the re-entry must include an appointment date with a clinician outside of UHCS after re-entry and be submitted with the request. Below are the request forms (PDF):
The Insurance and Referral Coordinators will be assistance in the MLOA process and in finding community referrals upon return from MLOA if needed. They can be reached at 617-373-2772 option #5.
Release of Medical Information
Since all your medical records are strictly confidential, you must provide us with a written request specifying information desired and where you wish it to be sent. This form may be downloaded at Release of medical information (PDF). Fax to: 617-373-2601.
This request of information (ROI) must include:
- your name and address
- telephone number and e-mail address
- school ID number
- dates attended (including when you left and whether or not you graduated)
- your signature
When you have graduated, send us a ROI and we'll send your records to the office of your new primary care practitioner.
Please allow at least two (2) weeks to process the request. If there is an urgent need for medical records for clinical care, please call us at (617) 373-3275 to let us know the request must be expedited.