Student Health Form

Personal Information

Name*

First Middle Last

Preferred name*

Date of Birth*

Gender*

Male
Female

Housing*

Birth place*

City State / Province / Region Country

Contact Information

Current Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Are you a foreign student?*

Yes
No

Mobile Phone*

Home Phone

Email*

Enter Email Confirm Email

Emergency Contact 1

Name of emergency contact*

Relationship to student*

Phone number of contact*

Emergency Contact 2

Name of emergency contact*

Relationship to student*

Phone number of contact*

Emergency Contact 3

Name of emergency contact

Relationship to student

Phone number of contact

Medical Information

Please list any medications you take regularly. Include both prescription and over the counter.

Do you have any allergic reactions to either food or medications?*

Food
Medicines
Both
Neither

Plese provide a list of your allergies and give any necessary details*

Check any of the following medical conditions that require ongoing care*

Please specify your type of allergies or reactions condition and provide any necessary details*

Please specify your type of anemia condition and provide any necessary details*

Please specify your type of anorexia/bulimia condition and provide any necessary details*

Please specify your type of bone or joint condition and provide any necessary details*

Please specify your type of cancer condition and provide any necessary details*

Please specify your type of depression condition and provide any necessary details*

Please specify your type of diabetes condition and provide any necessary details*

Please specify your type of gastrointestional condition and provide any necessary details*

Please specify your type of headaches and provide any necessary details*

Please specify your type of hearing/sight condition and provide any necessary details*

Please specify your type of heart condition and provide any necessary details*

Please specify your type of high blood pressure condition and provide any necessary details*

Please specify your type of immune disorder condition and provide any necessary details*

Please specify your type of mental illness condition and provide any necessary details*

Please specify your type of obesity condition and provide any necessary details*

Please specify your type of permanent physical disability condition and provide any necessary details*

Please specify your type of pulmonary/asthma condition and provide any necessary details*

Please specify your type of seizure condition and provide any necessary details*

Please specify your type of skin condition and provide any necessary details*

Please specify your type of condition and provide any necessary details*

Insurance Information

Faulkner University strongly encourages each student to have health insurance coverage. If you do not have coverage, please request an information brochure regarding affordable health insurance coverage.

Do you have health insurance?*

Yes
No

Faulkner University strongly encourages each student to have health insurance coverage. If you do not have coverage, please request an information brochure regarding affordable health insurance coverage from Senta Bargel by calling her at 334 386-7183 by email at sbargel@faulkner.edu

Insurance Carrier*

Carrier Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Carrier Phone*

Policy Number*

Group/Certificate Number*

Policy Holder*

First Last

Name of policy holder

Address of Policy Holder*

Street Address City State / Province / Region ZIP / Postal Code Country

Acknowledgement of Receipt and Agreement to Privacy and Drug Policy

University Health Services Privacy Notice

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The Faulkner University Health Center (“Facility,” “we” or “us”) is required under the federal health care privacy rules (the "Privacy Rules"), to protect the privacy of your health information, which includes information about your health history, symptoms, test results, diagnoses, treatment, and claims and payment history (collectively known as Protected Health Information). We are also required to provide you with this Privacy Notice regarding our legal duties, policies and procedures to protect and maintain the privacy of your Health Information. We are required to follow the terms of this Privacy Notice unless (and until) it is revised. We reserve the right to change the terms of this Privacy Notice and to make the new notice provisions effective for the Health Information that we maintain and use, as well as for any Health Information that we may receive in the future. Should the terms of this Privacy Notice change, we will make a revised copy of the notice available to you. Revised Privacy Notices will be available at our Facility for individuals to take with them, and we will post a copy of revised Privacy Notices in a prominent location in our Facility. This Privacy Notice will also be posted and made available electronically on our web site.

Permitted Uses and Disclosures of Your Health Information.

General Uses and Disclosures. Under the Privacy Rules, we are permitted to use and disclose your Health Information for the following purposes, without obtaining your permission or Authorization:

Treatment. We are permitted to use and disclose your Health Information in the provision and coordination of your health care. For example, we may disclose your Health Information to your primary health care provider, consulting providers, and to other health care personnel who have a need for such information for your care and treatment.

Payment. We are permitted to use and disclose your Health Information for the purposes of determining coverage, billing, and reimbursement. This information may be released to an insurance company, third party payer, or other authorized entity or person involved in the payment of your medical bills and may include copies or portions of your medical record that are necessary for payment of your bill. For example, a bill sent to your insurance company may include information that identifies you, your diagnosis, and the procedures and supplies used in your treatment.

Health Care Operations. We are permitted to use and disclose your Health Information for our health care operations, including, but not limited to: quality assurance, auditing, licensing or credentialing activities, and for educational purposes. For example, we may use your Health Information to internally assess our quality of care provided to patients.

Uses and Disclosures Required by Law. We may use and disclose your Health Information when required to do so by law, including, but not limited to: reporting abuse and neglect; in response to judicial and administrative proceedings; in responding to a law enforcement request for information; or in order to alert law enforcement to criminal conduct on our premises or of a death that may be the result of criminal conduct.

Public Health Activities. We may disclose your Health Information for public health reporting, including, but not limited to: reporting communicable diseases and vital statistics; product recalls and adverse events; or notifying person(s) who may have been exposed to a disease or are at risk of contracting or spreading a disease or condition.

Abuse and Neglect. We may disclose your Health Information to a local, state, or federal government authority, including social services or a protective services agency authorized by law to receive such reports, if we have a reasonable belief of abuse or neglect.

Regulatory Agencies. We may disclose your Health Information to a health care oversight agency for activities authorized by law, including, but not limited to, licensure, investigations and inspections. These activities are necessary for the government and certain private health oversight agencies to monitor the health care system, government programs, and compliance with civil rights.

Judicial and Administrative Proceedings. We may disclose your Health Information in judicial and administrative proceedings, as well as in response to an order of a court, administrative tribunal, or in response to a subpoena, summons, warrant, discovery request, or similar legal request.

Law Enforcement Purposes. We may disclose your Health Information to law enforcement officials when required to do so by law.

Coroners, Medical Examiners, Funeral Directors. We may disclose your Health Information to a coroner or medical examiner. This may be necessary, for example, to determine a cause of death. We may also disclose your health information to funeral directors, as necessary, to carry out their duties.

Organ Donation.We may disclose your Health Information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of cadaveric organs, eyes, or tissues.

Research. Under certain circumstances, we may disclose your Health Information to researchers when their clinical research study has been approved and where certain safeguards are in place to ensure the privacy and protection of your Health Information.

Threats to Health and Safety. We may use or disclose your Health Information if we believe, in good faith, that the use or disclosure is necessary to prevent or lessen a serious or imminent threat to the health or safety of a person or the public, or is necessary for law enforcement to identify or apprehend an individual.

Specialized Government Functions. If you are a member of the U.S. Armed Forces, we may disclose your Health Information as required by military command authorities. We may also disclose your Health Information to authorized federal officials for national security reasons and the Department of State for medical suitability determinations.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release your Health Information to the correctional institution or law enforcement official, where such information is necessary for the institution to provide you with health care; to protect your health or safety, or the health or safety of others; or for the safety and security of the correctional institution.

Workers' Compensation. We may disclose your Health Information to your employer to the extent necessary to comply with Alabama laws relating to workers' compensation or other similar programs.

Fundraising. We may use or disclose your Health Information to make a fundraising communication to you for the purpose of raising funds for our own benefit. Included in such fundraising communications will be instructions describing how you may ask not to receive future communications.

Marketing. We may use or disclose your Health Information to make a marketing communication to you that occurs in a face-to-face encounter with us or that concerns a promotional gift of nominal value provided by us.

Appointment Reminders/Treatment Alternatives. We may use and disclose your Health Information to remind you of an appointment for treatment and medical care at our Facility or to provide you with information regarding treatment alternatives or other health-related benefits and services that may be of interest to you.

Business Associates. We may disclose your Health Information to business associates who provide services to us. Our business associates are required to protect the confidentiality of your Health Information.

Other Uses and Disclosures. In addition to the reasons outlined above, we may use and disclose your Health Information for other purposes permitted by the Privacy Rules.

Uses and Disclosures That Require Patient Opportunity to Verbally Agree or Object. Under the Privacy Rules, we are permitted to use and disclose your Health Information: (i) for the creation of facility directories, (ii) to disaster relief agencies, and (iii) to family members, close personal friends or any other person identified by you, if the information is directly relevant to that person's involvement in your care or treatment. Except in emergency situations, you will be notified in advance and have the opportunity to verbally agree or object to this use and disclosure of your Health Information.
Uses and Disclosures That Require Written Authorization. As required by the Privacy Rules, all other uses and disclosures of your Health Information (not described above) will be made only with your written Authorization. For example, in order to disclose your Health Information to a company for marketing purposes, we must obtain your Authorization. Under the Privacy Rules, you may revoke your Authorization at any time. The revocation of your Authorization will be effective immediately, except to the extent that: we have relied upon it previously for the use and disclosure of your Health Information; if the Authorization was obtained as a condition of obtaining insurance coverage where other law provides the insurer with the right to contest a claim under the policy or the policy itself; or where your Health Information was obtained as part of a research study and is necessary to maintain the integrity of the study.

Patient Rights.

You have the following rights concerning your Health Information:

Right to Inspect and/or Copy Your Health Information From The Facility. Upon written request to the Facility, you have the right to inspect and copy your own Health Information contained in a designated record set, maintained by or for the Facility. A "designated record set" contains medical and billing records and any other records that we use for making decisions about you. However, we are not required to provide you access to all the Health Information that we maintain. For example, this right of access does not extend to psychotherapy notes, or information compiled in reasonable anticipation of, or for use in, a civil, criminal or administrative proceeding. Where permitted by the Privacy Rules, you may request that certain denials to inspect and copy your Health Information be reviewed. If you request a copy or summary of explanation of your Health Information, we may charge you a reasonable fee for copying costs, including the cost of supplies and labor, postage, and any other associated costs in preparing the summary or explanation
Right to Request Restrictions on the Use and Disclosure of Your Health Information From The Facility. You have the right to request restrictions on the use and disclosure of your Health Information for treatment, payment and health care operations, as well as disclosures to persons involved in your care or payment for your care, such as family members or close friends. We will consider, but do not have to agree to, such requests.
Right to Request an Amendment of Your Health Information From The Facility. You have the right to request an amendment of your Health Information. We may deny your request if we determine that you have asked us to amend information that: was not created by us, unless the person or entity that created the information is no longer available; is not Health Information maintained by or for us; is Health Information that you are not permitted to inspect or copy; or we determine that the information is accurate and complete. If we disagree with your requested amendment, we will provide you with a written explanation of the reasons for the denial, an opportunity to submit a statement of disagreement, and a description of how you may file a complaint.
Right to an Accounting of Disclosures of Your Health Information From The Facility. You have the right to receive an accounting of disclosures of your Health Information made by us within six (6) years prior to the date of your request. The accounting will not include: disclosures related to treatment, payment or health care operations; disclosures to you; disclosures based on your Authorization; disclosures that are part of a Limited Data Set; incidental disclosures; disclosures to persons involved in your care or payment for your care; disclosures to correctional institutions or law enforcement officials; disclosures for facility directories; or disclosures that occurred prior to April 14, 2003.
Right to Alternative Communications From The Facility. You have the right to receive confidential communications of your Health Information by a different means or at a different location than currently provided. For example, you may request that we only contact you at home or by mail.
Right to Receive a Paper Copy of this Privacy Notice. You have the right to receive a paper copy of this Privacy Notice upon request, even if you have agreed to receive this Privacy Notice electronically.

If you want to exercise any of these rights, please contact our Privacy Officer—University Nurse. All requests must be submitted to us in writing on a designated form (which we will provide to you), and returned to the attention of our Privacy Officer at the address below.

Contact Information and How to Report a Privacy Rights Violation.

If you have questions and/or would like additional information regarding the uses and disclosures of your Health Information, you may contact our Privacy Officer at:

University Health Center 5345 Atlanta Highway Montgomery, AL 36109

If you believe that your privacy rights have been violated or that we have violated our own privacy practices, you may file a complaint with us. You may also file a complaint with the Secretary of DHHS at

Region IV, Office of Civil Rights, U.S. Department of Health and Human Services at Atlanta Federal Center, Suite 3B70, 61 Forsyth Street, S.W., Atlanta, Georgia 30303-8909, voice phone (404) 562-7886, Fax (404) 562-7881, and TDD (404) 331-2867.

Complaints filed directly with the Secretary must be made in writing, name us, describe the acts or omissions in violation of the Privacy Rules or our privacy practices, and must be filed within 180 days of the time you knew or should have known of the violation. Complaints submitted directly to us must be in writing and to the attention of our Privacy Officer. There will be no retaliation for filing a complaint.

University Alcohol, Drugs and Tobacco Policies

Purpose: The purpose of this policy is to ensure that no employee or student under any circumstance comes to work/school or university functions under the influence of drugs/alcohol and to ensure all employees and students abide by the laws pertaining to alcohol and drug use.

GENERAL PROVISIONS

This policy is adopted to ensure compliance with applicable Federal law and therefore addresses only the unlawful possession, use or distribution of alcohol or illegal drugs by students and employees. The University has other policies that address circumstances where the possession, use or distribution of alcohol is not unlawful but is still a violation of student or employee conduct regulations.

The University has both a legal and moral obligation to maintain a drug-free learning environment and a drug-free workplace for the University. Therefore, in accordance with the Drug-Free Workplace Act of 1988 PL 100-690 and the Drug-Free Schools and Communities Act Amendments of 1989 PL 101-226, Faulkner University has adopted an official policy on maintaining a drug-free community and workplace.

The Drug-Free Schools and Communities Act Amendments of 1989 require that, as a condition of receiving funds or any other form of financial assistance under any federal program, an institution of higher education must certify that it has adopted and implemented a program to prevent the unlawful possession, use or distribution of illicit drugs and alcohol by students and employees.

The University shall distribute annually, in writing, to each student (regardless of the length of the student's program of study) and each employee (regardless of classification, status, percent of time, etc.) the following information:
The standards of conduct that clearly prohibit the unlawful manufacture, distribution, dispensation, consumption, possession or use of illicit drugs and alcohol by students and employees on the institution's property or as a part of any of its activities;

A description of the health risks associated with the use of illicit drugs (controlled substances) and the abuse of alcohol;

A description of available drug or alcohol counseling, treatment, or rehabilitation or re-entry programs;
A description of applicable legal sanctions under local, state or federal law; and

A statement specifying the actions which will be taken against students and employees violating the policy, including termination of employment, expulsion from the University, referral for prosecution, or mandatory participation in a rehabilitation program.
The University shall review the program, biennially at a minimum, to determine its effectiveness, ensure that disciplinary sanctions are enforced, and make changes to the program if warranted.
Upon request by the Secretary of the U.S. Department of Education, the University shall make available personnel records and other information as necessary for a program review by the Secretary.

Standards of Conduct

The unlawful possession, use, consumption, manufacture, distribution, or dispensation of alcohol or controlled substances on Faulkner University property, in the workplace of any employee, or as any part of any University function or activity, whether held on or off campus, by any employee or student of the University is strictly prohibited.

SPECIFIC REQUIREMENTS AND SANCTIONS

Students

Any student who violates this policy is subject to discipline or sanction consistent with applicable University procedures. Additionally, a student may be referred for prosecution under applicable local, state, or federal laws.

Requirements- Students may not manufacture, distribute, dispense, consume, possess or use alcohol or illegal drugs on any property owned or leased by Faulkner University or at any University sponsored or sanctioned event. Students must notify the appropriate University administration (usually the Dean of Students) of any alcohol or drug-related criminal conviction for a violation occurring on Faulkner University property, in any University facilities, or as any part of activities sponsored by or participated in by Faulkner University, within five (5) days of the date of such conviction. Within ten (10) days after having received such notice of conviction of any student for any alcohol or drug-related offence, Faulkner University will notify the appropriate federal funding agency if required.

Students should contact the Office of Student Services or the Dean of Students office if they are having a problem with drugs or alcohol or become aware of problems occurring with another student.

Sanctions- A student found in violation of the policy shall be subject to discipline and/or dismissal as provided for in the Faulkner University Student Handbook applicable to such student. Additionally, said student shall be subject to the sanctions imposed by the University on a case-by-case basis, with regard to the severity of the violation. These sanctions may include probation, suspension, expulsion, fines, termination of employment, referral for substance abuse treatment, and/or referral to appropriate legal authorities.

Employees

Any University employee who violates this policy is subject to discipline or sanction consistent with applicable University procedures. For employees, disciplinary action may include dismissal, as well as lesser sanctions. Additionally, an employee may be referred for prosecution under applicable local, state, or federal laws.

Requirements- As a condition of employment, each employee must agree to abide by the terms of the drug-free policy of Faulkner University. Additionally, the use of alcohol off University premises that adversely affects an employee's work performance, or an employee's safety or the safety of others is strictly prohibited. Each employee agrees to notify his or her immediate department supervisor not later than five (5) days after conviction for violation of any criminal drug statute occurring in the workplace. The department or division head must report this information to Human Resources. If the convicted employee is employed under a contract or grant, Faulkner University will notify granting or contracting agencies within ten (10) days after receiving notice of a criminal drug statute conviction.

Employees should contact the Human Resources office if they are having a problem with drugs or alcohol or become aware of problems occurring with another employee.

Sanctions- Any employee who violates this policy shall be subject to discipline and/or dismissal, with regard to the severity of the violation. These sanctions may include suspension, termination of employment, referral for substance abuse treatment, and/or referral to appropriate legal authorities.

LEGAL PENALTIES

Anyone convicted of an alcohol or drug related offense is subject to a wide range of penalties on the local, state, and federal levels. These sanctions vary, but may range from fines and probation for minor violations to life imprisonment for violations such as drug trafficking.

SMOKE FREE UNIVERSITY

Purpose: The purpose of this policy is to ensure compliance with all city and state guidelines related to smoking.

GENERAL PROVISIONS

Faulkner University is committed to providing a healthy, comfortable, and productive environment for the students, faculty, and staff of the university. This University operates in accordance with the SB126 Alabama Clean Indoor Air Act and Alabama Department of Public Health regulations.

Faulkner University is entirely smoke free.

This policy applies to all students, faculty, staff, and visitors. Copies of this policy shall be distributed to all faculty and staff and shall be included with information given to all admitted students. Signs are posted on each campus to notify visitors and the University community.

This policy applies to all Faulkner University facilities and vehicles, owned or leased, regardless of location. Smoking shall not be permitted in:

Any University buildings, including private residential space within university housing;

Any University vehicles;

Outdoor seating or serving areas of University eating facilities;

Outdoor arenas, stadiums, any seating areas or concession stands; or

Bleachers and other seating areas used for spectators at sporting and other University events.

No tobacco-related advertising or sponsorship shall be permitted on university property, at university-sponsored events, or in publications produced by the university, with the exception of advertising in a newspaper or magazine that is not produced by the university and which is lawfully sold, bought, or distributed on university property. For the purposes of this policy, "tobacco related" applies to the use of a tobacco brand or corporate name, trademark, logo, symbol, or motto, selling message, recognizable pattern or colors, or any other indicia of a product identical to or similar to, or identifiable with, those used for any brand of tobacco products or company which manufactures tobacco products.

Cigarettes shall not be sold on university grounds, either in vending machines or from any area on campus.

The success of this policy depends on the thoughtfulness, consideration, and cooperation of smokers and nonsmokers. All students, faculty, and staff share in the responsibility for adhering to and enforcing this policy. Violators of this policy may be subject to disciplinary action.

Questions and problems regarding this policy should be handled through existing departmental administrative channels and administrative procedures.

Signature*

By checking this box, I acknowledge that I have read, understand and agree to the privacy and drug policy listed above.*

Immunizations, TB Skin Test Result, and Form Submission

Do you have your immunizations card and your skin test results, as required by University policy?*

Yes
No

A copy of your Immunization card report and your TB skin test results must be sent if available. How would you prefer to submit these?*

Mail (instructions below)
Fax (instructions below)
Upload (instructions below)

Mailing Instructions:

Please mail your immunizations card and your TB skin results to:

Faulkner University Health Center 5345 Atlanta Highway Montgomery, AL 36109

Fax Instructions:

Please fax your immunizations card and your TB skin results to: 334-386-7523

Please upload your immunization records and TB skin test results*

Drop files here or

Max. file size: 2 MB.

Accepted file types are: .pdf, .doc, .jpeg, .jpg, .png

Signature*

I agree that the above information is accurate to the best of my knowledge, and that I am the person whose name appears on this form*

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Introduction