Health Forms and Policies
All visits to the Health Center are confidential.
Our staff maintains strict confidentiality with your medical records at all times. Medical records of all patients seen at the student health center are retained for 7 years after the last patient visit. Medical records are not transferred to micro fische.
All patients seen at Student Wellness Services are entitled to rights and responsibilities pertaining to their care. It is important that all rights and responsibilities related to patient/client care are identified, documented, and communicated to everyone seeking care at Student Wellness Services. If you have any questions, any staff member can help you understand these rights and responsibilities.
View the full Patient/Client Rights and Responsibilities document.
- Advanced Health Care Directive Form - Fillable
- Agreement to Treatment (PDF)
- Hospital Preparedness Form - Fillable
- Medical Leave - Community Provider Report Form (PDF)
- Notice of Privacy Practices (PDF)
- Patient/Client Rights and Responsibilities (PDF)
- Release of Information and Records Consent Form (PDF)
- Vaccination Exemption Form
Fill out the Release of Information and Records Consent Form (PDF)
Manner of Release:
Records will be ready for release within 5-7 business days. Please indicate in your message how you would like your records to be released. Records may ONLY be released by in-person pick up, fax or sent via postal service. You will be contacted by phone or email when they are ready to be released.
Fee Schedule for Copies of Records:
- 1-3 pages: no charge
- 4-10 pages: $5.00
- 11-20 pages: $10.00
- 21+ pages: $15.00 plus $0.35 per page
- Records sent directly to a new provider: $0.00
Payment is only accepted by cash or check. You may also pay with an active bursar account.
Please Note: Records are only kept for up to 7 years from the date of degree conferred.
We do not provide this service.
Student Wellness Services does not routinely provide medical excuse notes or visit verification for students who miss class or assignments due to minor illnesses or injury. Students experiencing illness or other health conditions are encouraged to seek treatment at Student Wellness Services, where the illness or injury can be assessed and treated. If a student is moderately to severely ill, contagious, or is otherwise advised to avoid class, a clinician may, with student permission, communicate this to the deans' office. The deans may assist students by supporting academic accommodations or extensions; see the deans' office website for relevant policies around academic extensions for medical reasons.
Students experiencing minor illnesses, allergies, and injuries are encouraged to directly contact their instructors or teaching assistants and request any extensions or flexibility with coursework.
In the event a student experiences an ongoing health concern that impacts their academic ineligibility, Student Wellness Services clinicians may, with student permission, consult with the deans' office for the purposes of medical incomplete grades or a voluntary medical leave. Students who have not been under the care of a Student Wellness Services clinician or who present with only a historical account of illness or health concern will not receive a recommendation from Student Wellness Services.
Student Wellness Services does not perform clinical assessment, diagnosis, or documentation for disabilities. Students who wish to pursue academic accommodations for a disability are encouraged to contact Caltech Accessibility Services for Students (CASS) to learn about registration and requirements. Student Wellness Services can provide referrals to appropriate clinicians in the community, if desired.
Student Wellness Services does not provide documentation for disability accommodations, emotional support animals, housing, or dining exceptions. Practitioners are able to provide referrals to off-campus providers for neuropsychological assessment, psychoeducational evaluations, or other documentation needs. Student Wellness Services providers can consult with an assessor or off-campus provider (with a signed release of information) if the student has been in treatment or the provider has information to contribute to the evaluation and documentation process.
Please visit the Caltech Accessibility Services for Students (CASS) website for full information on the accommodation process.
The Confidential Health Information Act (CHIA) provides Californians insured under another person's health insurance policy new confidentiality protections. These protections will allow them to submit a confidential communications request form to receive communications from their health plan directly regarding their receipt of sensitive services or any service if they feel disclosure of related information to the main policyholder could cause harm.