Forms

If you have any questions about any of these forms, please call Health Services at 585-245-5736 or Counseling Services at 585-245-5716.

Authorization to Release Information Form

Release of Personal Medical/Health Information
This form grants the Health & Counseling department permission to share information with others, including health care providers, family members, Geneseo staff, and anyone else who you might designate. 

Signed releases of information, authorized by the patient, are time-limited, with written specified dates, and are diagnosis related. Releases cannot be for broad, unlimited periods of time, such as a semester, academic year or covering the span of time for which the student attends SUNY Geneseo. Exceptions may be made in cases of patient or legal requests for complete medical records.

Authorization to Release Information Form 

If you are in need of your medical records, complete the above form and a Request for Immunization or Medical Record

Immunization/Physical Verification Forms 

Verification for Immunization/Physical
These form should be completed by your Physician or Health Care Professional . Once completed upload each of them to your Geneseo myhealth.geneseo.edu  account.

Immunization Form 
Physical Form 

Request Immunization/Medical Records

Immunization/Medical Records Request
If you are a current student (or graduated with in the last 3 months) you may view and print a copy of your immunizations.

• Login to My Health at https://myhealth.geneseo.edu
• Click on Immunizations link on the left navigation bar.
• Locate the Print button in the top right corner and click to print.

If you are NOT a current student and would like your immunization records and/or complete medical/treatment records, you will need to complete the Request for Immunizations or Medical Records form.

There is no charge for requesting your immunization records. There is a nominal charge of $8.00 for the release of your complete medical/treatment records.  Payment is required in either a check made out to SUNY Geneseo or credit card.

Form Submission (Please allow 3-5 business days for processing):

• Email your request to immunization@geneseo.edu
• Mail your request to Lauderdale Health Center, 1 College Circle, SUNY Geneseo, Geneseo, NY, 14454 (be sure to include payment if applicable)
• Fax your request to 585-245-5744

Request for Immunization or Medical Record

Minor Student Forms

Minor Students Seeking Counseling
If you are under the age of 18 and seeking counseling services, you will need either provide parental consent OR document that your parents have refused/are unable to provide parental consent.  The first form below is the Parental Consent Form; the second is the Minors' Consent Form.
Parental Consent 
Minors Consent 

Other Forms

Religious Exemption
If you hold a deep religious conviction that prohibits you from participating in the routine vaccination program, you need to fill out the form and submit it as a waiver for the New York State required immunizations.
Religious Exemption 

Counselor Change Request
If you have been seeing a therapist in Counseling Services and would like to work with someone new (same academic year), print the form below, complete the requested information, and drop it off at Counseling Services, Lauderdale 205.
Counselor Change Request