Medical Forms & Policies
Forms & Documents
- NEW! Affordable Care Act (ACA) & College Students Information
- Medical History/Immunization Form/TB Questionnaire
- Consent to Release Information Form
- Student Health Plan
Medical Consent/Medical History
Complete the Student Information and Medical Consent sections of the Medical History Form. A Medical Consent form from you or parent/legal guardian (if you are a minor), is required to receive medical services at the health center.
Immunization/TB Questionnaire (Mandatory)
Louisiana Law (R.S. 17:170/R.S. 17:170.1/Schools
of Higher Learning) requires that all students entering Grambling State
University to be immunized for the following: Measles (2 doses), Mumps,
Rubella--required for those born on or after January 1, 1957; Tetanus-Diphtheria
(within the past 10 years); and against Meningococcal disease (Meningitis).
For more information on meningitis, click the following link: http://www.cdc.gov/meningitis/about/faq.html
The student health center is evaluating all entering students for exposure to tuberculosis (TB). Failure to return this questionnaire will result in you being placed on hold.
You will not be eligible to pay University fees until all immunization records are in compliance or the exemption is signed. Medical History/Immunization Form/TB Questionnaire.
Consent to Release Information Policy
Students may request their medical records to be released in person, by mail, or by fax. Medical records are personal and private and cannot be released without your written permission, except as required by law. Please be prepared to provide a picture ID when requesting medical records and allow five business days to process the release of medical information. Consent to Release Information Form.
Student Medical Referral Policy
Referrals are required for all providers. Services will be paid at Out-of-Network rate if referral is not acquired. Students are not required to obtain a referral when the Student Health Center is closed, on vacation, the student is traveling beyond 35 miles from campus, or the student is no longer eligible to access the Student Health Center.
Students must present a validated ID card when reporting to Foster-Johnson Health Center for medical consultation and treatment.
Statement of Privacy Policies & Practices