Health Background Form

Provide information about your health history and immunizations.

If you did not yet read the informational immunizations and meningitis page in the Student Services Gateway, 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 Student Health Services; use one of the following methods:

In Person By Mail (USPS) By Fax
Student Health Services
Michael Hall,
 South Campus
Student Health Services
Michael Hall, 
South Campus
3435 Main Street
University at Buffalo

Buffalo, NY 14214
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

How to Know If UB Received Your Completed Medical and Immunization Records

Due to the high volume of paperwork we receive, we cannot answer individual requests about whether or not we received and processed your medical and immunization records. If we received your medical and immunization records and you have met the stipulated requirements, you will not have a hold on your student account. If your paperwork is not in compliance, you will receive an email from Student Health Services.

Upon receipt of your records/forms, it typically takes 2-3 business days for Student Health Services for processing. Please only contact us if you have a hold on your student account for a prolonged period of time after submitting your records/forms (more than 3 weeks after mailing or more than 3 business days after faxing).

About Medical Records

Health and immunization records submitted to or generated by Student 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 Student 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 Student Health Services

If other individuals or agencies have provided confidential information to Student 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