Revised Fall 2016
Medical Record Release
Name ____________________________________________________________________________
(PLEASE PRINT) FIRST NAME MIDDLE INITIAL LAST NAME
Address __________________________________________________________________________
CITY STATE ZIP
NJCU Student ID # ____________________ or Last 4 digits of SS # XXX – XX - ____________
D.O.B.____________ Year attended NJCU ____________ Contact Ph # ________________________
MO/ DAY/YEAR
TO OBTAIN COPIES OF YOUR RECORDS
(IMMUNIZATION OR MEDICAL)
FROM NEW JERSEY CITY UNIVERSITY:
TO OBTAIN COPIES OF YOUR RECORDS
(IMMUNIZATION OR MEDICAL)
FROM ANOTHER PHYSICAN OR SCHOOL OUTSIDE OF
NEW JERSEY CITY UNIVERSITY:
I hereby authorize New Jersey City University,
Health and Wellness Center, to release a copy of the
medical/immunization records requested below.
I hereby authorize you to release to New Jersey
City University, Health and Wellness Center, a copy
of my medical and/or immunization records request
below.
Information to be released (please check):
□ Immunization Record only
□ Entire Medical Record*
□ Other (Please specify) ____________________
* Please note that we only have medical records that you have provided to
us and/or any record of treatment at NJCU Health & Wellness Center.
Information to be released (please check):
□ Immunization Record only
□ Entire Medical Record
□ Other (Please specify) ____________________
Please send my records to:
Name: __________________________________
Address: ________________________________
________________________________________
□ Fax #______________________
□ Email:______________________
□ Copy taken in-person by student
Please send my records to:
NJCU HEALTH & WELLNESS CENTER
VODRA HALL, SUITE 107
2039 Kennedy Blvd., Jersey City, NJ 07305
FAX # 201-200-2011
EMAIL: HWC@NJCU.EDU
Signature (Required)________________________________________ Date ___________
MO/ DAY/YEAR
Witness ___________________________________________________________________
NJCU HEALTH & WELLNESS CENTER - VODRA HALL, SUITE 107
2039 John F. Kennedy Blvd., Jersey City, NJ 07305
PH # 201-200-3456 - FAX # 201-200-2011 – EMAIL: HWC@NJCU.EDU
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