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SHS Forms

Available Forms


How To Obtain Your Health Information

Download and complete the Authorization for Use and Disclosure of Protected Health Information Form in its entirety send along with a copy of your drivers license or student ID card. All forms must be signed and dated. These forms can be mailed or faxed to Student Health Services. Mailing and fax information are located at the bottom of the page. Requests without signatures will be returned.

You may also request records in person by stopping by the Student Health Services Health Information Management (HIM) Department and completing the form. The HIM Department accepts no requests for records via telephone.

Processing time for all health records is within 5 business days.

Obtaining Copies of Your Medical Charges

Protecting Patient Privacy is a High Priority!
Protecting patient privacy is a high priority at Student Health Services. Due to federal regulations, we are not permitted to discuss your medical information over the telephone. Additionally, we can only discuss this information with you, the patient, and not your parents (unless you are under the age of 18), family members, spouse, or friends. If you need copies of your billing and pharmacy records, it is your responsibility to request the information. This can be done:

In Person:

Stop by The Insurance Offices – Rooms 154 & 155 – on the first floor of Gove Student Health Center to request copies of billing and pharmacy charges. Be sure to bring one form of photo identification — drivers license, UNCG Student ID, UNCG SpartanCard, etc. You will be asked to complete the Authorization for Use and Disclosure of Protected Information Form. Once this is complete and your photo identification has been verified, we can often assist you right at that moment for one or two copies. Otherwise, you will be contacted when the information is ready for pickup or it will be mailed to you.

By Mail or Fax:

Once you have completed the Authorization for Use and Disclosure of Protected Information Form, you may either mail or fax it to:

Student Accounts Receivable Office
Student Health Services
Anna M. Gove Health Center
Post Office Box 26170
Greensboro, NC 27402-6170
FAX: (336) 334-5357

Once we receive your completed form, we will compare your signature with a signature on file in your medical record. If the signatures are verified, copies will be sent to the address indicated on the Authorization for Use and Disclosure of Protected Information Form. If the signatures do not appear to match, we will request additional information from you to verify the authenticity of the request.

Immunization Forms

The Counseling Center Walk-In Form