Health Background Form

Provide information about your health history and immunizations.

If you did not yet read the informational immunization and meningitis requirements, please do that before completing and submitting this form.

Don't Miss Class Registration

Students cannot register for classes until they have fulfilled the immunization and meningitis information requirements listed on this form.

Download the Form

For the best experience use a non-mobile device.

Important Requirements

- This form requires the signature or stamp of your health care provider.

- Your health care provider must provide the requested information on this form. Students are not allowed to fill it out themselves.

-This form must be completed in English.

Submit Your Forms

Please do not email medical records to Health Services; use one of the following methods:

Submitting Your Records
In Person By Mail (USPS) By Fax
Health Services
Michael Hall, South Campus
Health Services
Michael Hall, South Campus
3435 Main Street
University at Buffalo
Buffalo, NY 14214
716-829-2564
International Student Recommendations

• Send your forms as soon as possible to facilitate class registration (consider air mail or an express courier)

• Do not return the forms to International Admissions

• Note: scanned copies and e-mail attachments are not permitted

Did UB Receive My Medical and Immunization Records?

New/Incoming Students

Once your immunization records have been received, processed, reviewed and deemed compliant with requirements by our immunization coordinator, your IMM and MEN holds will be removed; this will be reflected in your HUB Student Center in real time. This will occur 2-3 business days after we receive your compliant records.

Students will not be individually contacted to confirm receipt of records. Please check the HUB system for the current status of your service indicators.

If your paperwork is not in compliance, you will receive an email from Health Services.

Please contact us only if you have a hold on your account for a prolonged period of time after submitting your records/forms:

  • More than 7 business days after faxing or bringing in-person
  • More than 3 weeks after mailing

Returning Students in a Health-Related Program

Please allow 10 business days for Health Services to process your records and update UBlearns.

About Medical Records

Health and immunization records submitted to or generated by Health Services are held on file for 10 years.

Information About Students Over the Age of 18

In accordance with HIPAA (Health Insurance Portability and Accountability Act), if a patient is 18 years of age or older we cannot release any medical information to a parent, spouse, instructor, employer or anyone else other than the patient him/herself. Patients who would like Health Services to verify an appointment or discuss diagnosis and treatment with anyone other than themselves must sign an authorization consent form during their visit. This consent pertains to that day’s appointment only; a new release form must be signed at each visit.

Only for Health Care Provided by Health Services

If other individuals or agencies have provided confidential information to Health Services, you cannot use the authorization form to re-release this information. For copies of medical records that came from another individual or agency, please contact that original individual or agency directly.

To Submit this Form, or Get Help

Health Services

Student Life

University at Buffalo
Michael Hall, 3435 Main Street, South Campus
Buffalo, NY 14214

Phone: (716) 829-3316; Fax: (716) 829-2564