Student Health Form

If you see any problem with this form, please screenshot the error and send it to webmaster@faulkner.edu or ask for a physical copy from RN Senta Bargel.

Personal Information

First Name: Middle Name:
Last Name: Preferred Name:
Date of Birth: Gender: MaleFemale
Housing: Birth Place:

Contact Information

Address: City:
Country:

State/Province:
Zip: Foreign Student
Home Phone: Cell:
Email:

Emergency Contact Information

First Name Last Name Relation Phone
Contact One:
Contact Two:

Medical Information

Check the medical conditions that require ONGOING CARE.

Allergies/ReactionsAnemiaAnorexia/BulimiaBone/JointCancerDepressionDiabetesGastrointestinal
HeadachesHearing/SightHeartHigh Blood PressureImmune DisorderMental IllnessObesity
Permanent Physical DisabilityPulmonary/AsthmaSeizureSkinOther
Please EXPLAIN any areas checked above:


0/250
Please list any significant conditions, illnesses, diseases or surgeries you had in the past:


0/250
List current medications, including over the counter medication taken regularly:


0/250

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.
Carrier Carrier Address
Carrier Phone Policy #
Group/Certificate # Policy Holder
Policy Holder Address


Acknowledgement of Receipt and Agreement to Privacy Policy

Please read, carefully, the policies listed below.

You must select the checkbox below that signifies you have read, understand and agree to the policies below.

If you do not wish to do this at this time or you have questions regarding the policies listed below please contact the Health Center at 334.386.7183, fax at 334.386.7523 or by email at healthcenter@faulkner.edu.

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.

1. 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.



2. 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.



3. 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:



1. 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



2. 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.



3. 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.



4. 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.



5. 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.



6. 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.

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

Acknowledgement of Receipt and Agreement to Drug Policy

Please read, carefully, the policies listed below. You must select the checkbox below that signifies you have read, understand and agree to the policies below.

If you do not wish to do this at this time or you have questions regarding the policies listed below please contact the Health Center at 334.386.7183, fax at 334.386.7523 or by email at healthcenter@faulkner.edu.


University Alcohol, Drugs and Tobacco Policies


DRUG FREE UNIVERSITY

  Section: Standards of Conduct                                                                                 Effective:
May 1989

  Policy Number: 353                                                                                         Reviewed:
September 2009


Scope: Faculty, Staff, Students     

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.

  1. 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.
  2. 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.
  3. 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.
  4. 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

  Section: Standards of Conduct                                                                                   Effective:
April 1999

  Policy Number: 355                                                                                              Revised:
June 13, 2008


Scope: Faculty, Staff, Students, and Visitors     



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.





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

Immunizations, TB skin test result and Form Submission

Once you have agree to the policies, you need to send a copy of your Immunization card report and your TB skin test result to:

Faulkner University
Health Center
5345 Atlanta Highway
Montgomery, AL 36109

or fax 334-386-7523