Forms & Documents

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:

Registration Holds: Important Notice!

Federal Regulations (HIPAA) prohibit accepting personal, confidential, medical, or Immunization documentation through e-mail. Medical records can only be accepted by FAX (909-537-7027), mail, or in person.

"Health Holds" can not be cleared via e-mail. Please call 909-537-5241 if you have questions.


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.

  • 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.
  • 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.
  • 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.
  • Parental consent is required to provide health care to minors. 
    *(Exceptions- California Law: Request for contraception services, or an Emancipated Minor)
  • A Signed Waiver is required to decline immunization requirements due to personal, medical or religious beliefs. 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.

Concerns or Comments

Student concerns may be addressed to Grace Castillo Johnson, Ed.D., Director, Student Health Center and sent via e-mail to:  A suggestion box is available in the waiting room and the contents addressed per the QI committee. A patient satisfaction survey is conducted annually. Trends are analyzed and adjustments made as needed. A patient may appeal to the Title IX director, campus Ombudsman, or the Associate Vice President of Student Affairs. This reporting policy is posted on the patient Rights and Responsibilities poster displayed in the Health Center.