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Health Center
Orrico Hall Upper Level, MSC 147
5000 N Willamette Blvd.
Portland OR 97203
503-943-7134
health@up.edu

Health Center: Forms

If you are interested in learning more about our policies, or if you need to access one of our forms, you may download them here and print them directly from your computer. The forms we currently have available are listed below; if you do not see a form you need to complete, please contact the Health Center.

Release of Confidential Information
Students who wish to have the University Health Center (UHC) communicate with third parties about their health care, counseling or disability services must complete this authorization form. For example, if the student wishes the UHC staff to communicate with prior or current professional care providers, parents, or particular faculty in order to coordinate care or support processes, this authorization form would need to be signed for each entity to receive or exchange the privileged communications. By law and professional ethics, such signed authorizations are not required in the event of emergencies involving an imminent threat of harm. In such cases, the UHC staff can notify third parties of information necessary to attempt to prevent harm from occurring.

Health History Form
The Health History Form must be returned to the Health Center. Please note that Oregon state law requires that each entering full-time student must have two doses of measles vaccine or MMR vaccine (documented by month and year of each dose).

Confidentiality Statement and Consent to Treatment
Communication between you and University Health Center Staff are confidential as required (and except as limited) by law. Generally, information may not be disclosed to another person or agency outside of the University Health Center (including parents, teachers or Residence Life staff) without your written consent.

Current Student Health Insurance Information (Provided by Aetna Student Health)
The Health Insurance Program is required of all full-time undergraduate students at the University of Portland. If you have personal medical insurance coverage and would like to waive coverage provided by the University's group insurance plan, a Health Insurance Waiver must be completed through the Chickering Group's web site before the beginning of the academic term. Students will be billed for group coverage by student accounts each semester if a waiver has not been completed.