Please log into the Patient Portal located on the right. Please have your licensed medical provider complete and sign your form and upload the completed form to the Patient Portal. A completed and signed form is required to request declination of the COVID-19 vaccination requirement due to medical reasons. Your form will be reviewed and you will be notified of the approval status.
Completed forms can also be mailed to:
CSUSB Student Health Center
5500 University Parkway
San Bernardino, CA 92407
Emailed forms cannot be accepted. Please submit your completed form as soon as possible.
Please note: Students that are not fully vaccinated are required to test weekly for COVID-19 regardless of vaccine exemption status.
For questions, please contact the Student Health Center at 909-537-5241.
Absence Note Guidelines
The CSUSB Student Health Center provides two types of notes for class and both require a visit:
- Verification of visit for any scheduled appointment. This note verifies you were seen on a particular time and date, and nothing else. It does not include a diagnosis nor recommendations for missed activities.
- Medical documentation during visits for significant medical illness or injury requiring substantial time off from school.
We do not routinely provide medical excuse notes.
The majority of legitimate medical issues that cause students to miss class are due to conditions that get better on their own, such as colds, headaches, stomach flu, etc. These illnesses tend to be difficult to confirm objectively, especially after the fact.
In most cases these conditions improve with self-care (fluids, resting in bed) and do not require a medical visit.
The Documents section on this page contains links that will allow students to print an Absence Self-Verification Form, and a Letter to Faculty from the CSUSB Student Health Center, and articles explaining current best-practices set forth by the American College Health Association.
All medical records are strictly confidential. Information from records will not be released to any one without the written authorization of the patient, except as required by law. The staff at the Student Health Center can assist you with the following services:
- Requesting copies of your medical records
- Sending copies of your medical records to an outside provider
- Clearing Immunization holds
- General Standards of Patient Rights and Responsibilities (PDF)
Health information is confidential, and access is restricted to authorized CSUSB Student Health Center personnel ONLY. Information in the health record will not be released to parents (except in the case of minors), professors or anyone else without written consent or when required by law, court order or when subpoenaed.
- Advance Directive (PDF) An Advance Directive is a written document in the form of a living will or Durable Power of Attorney prepared by a competent individual that specifies what, if any, extraordinary procedures, surgeries, medication or treatments the patient desires in the future, when he or she can no longer make such decisions about medical treatment. Please see the attached form and instructions for more detailed information.
- Release of Medical Records form (PDF) Consent is required to release medical records to another facility or provider. Proof of identity is required to pick up records in person. Records cannot be mailed or faxed directly to students. Please indicate specific dates needed and allow 7-10 working days to process.
- Request for Medical Records (PDF) Consent is needed to release any medical records from an outside physician or health care facility that is mailed directly or faxed to the CSUSB Student Health Center.
- Consent for Medical Treatment of a Minor (PDF) Parental consent is required to provide health care to minors.
*(Exceptions- California Law: Request for contraception services, or an Emancipated Minor)
- Immunization Exemption Declaration (PDF) A Signed Waiver is required to decline immunization requirements due to medical reasons. Bring the verification form with proof of identity to the Student Health Center. NOTE: This waiver may bar students from campus in an outbreak situation for their own protection or that of the campus community.