Download Forms

You can do a lot on our website. But protecting the confidentiality of your medical records sometimes requires getting an actual signature on an actual sheet of paper.

Consent for Medical Treatment of a Minor

Students who are 17 years old or younger will need a parent or guardian’s Consent for Treatment.  Please print this form, complete it and either mail or fax it to the address or number at the top of the form. Click to Print.

Confidential Medical Information

Want to authorize release of information to another medical provider? Download the Authorization of Release of Information.

Want to confirm that we are not sharing your information with anyone you don't want to? Download the Notice of Privacy Practices Acknowledgment of Receipt.

Please note there will be a charge for copies except for requests for continuity of medical care.

Billing Information

Want to share information about specific IU Health Center charges with your parents or a third-party insurer? Download the IU Health Center Financial Operations Release of Information.

If you feel you have been charged inappropriately or incorrectly, submit a Request for Billing Review.

Immunization Forms

Referring Allergist Agreement

Allergist's Order Sheet 

Allergy Patient Dose Sheet

Student Request for Allergy Shots

Bring your completed forms to the IU Health Centers Immunization Department, or fax them to 812-856-8729.

Influenza Forms

Student Form

Employees, Graduate Appointees COVERED by an IU Medical Plan

Employees not on an IU Medical Plan