North Carolina A&T State University Sebastian Health Center 1601 E. Market Street Greensboro, NC 27411 336-334-7880 Office 336-256-2613 Fax GUIDELINES FOR COMPLETING THE REQUIRED MEDICAL HISTORY PACKET An Equal Opportunity / Affirmative Action Employer A Constituent Institution of THE UNIVERSITY OF NORTH CAROLINA SYSTEM Rev 05/10; 10/10;2/11 The Sebastian Health Center welcomes you to the University. A variety of medical and health services are provided for all registered students between the hours of 8:00 a.m. and 9:00 p.m. (Monday - Friday). This Report of Medical History is designed to collect information about your health history and to verify that your immunizations are in compliance with the N.C. Immunization law. North Carolina state law requires all undergraduate and graduate students taking 4 hours or more on campus to provide documented proof of the required immunizations before registering for classes. These forms [“A” Report of Medical History, “B” Family & Personal Health History, “C” Immunization Record, “D” Physical Examination (Required for Special Groups), “E” Meningococcal Vaccine Acknowledgement, and “F” HIPAA Acknowledgment] must be on file with the Student Health Center prior to May 15 th for fall registration and December 1 st for spring registration. If you are admitted to the university after the above dates, please return your information before your scheduled new student orientation date. Completion of these forms is required to finalize your acceptance to North Carolina A&T State University. Enrollment suspension procedures from classes will take place 30 days after registration, until immunizations and requirements are documented. Do not complete this form in pencil. Use a black ink ballpoint pen or type. Attach copies of immunization records obtained from high school, military service and medical facilities, that may be used towards meeting the immunization requirements. NOTE: RECORDS MUST HAVE AN OFFICIAL SEAL / STAMP OR PHYSICIAN’S SIGNATURE TO BE VALID. If you have not received two (2) Measles, Mumps Rubella, you will be required to receive two (2) dosages (an initial dose and the second dose within (6) weeks). Give special attention to showing proof of the Tetanus series: 3 doses of DTP / DTaP / Td and a Tetanus Booster (Tdap) within the last 10 years. A Physical Examination is recommended. The physical form should be completed by a licensed physician for all incoming freshmen and transfer students to the University prior to the first day of class. Special Groups are required to complete the Physical Examination and Sickle Cell Testing. ( Band, ROTC, Student Athletes, Intramural Sports). International students are required to provide proof of a negative PPD/Tuberculin skin test within 12 months proceeding the first day of classes. If your PPD/TB is positive, a chest x-ray may be performed within the United States. Students requesting medical exemption regarding NC Immunization Laws, are required to have a MEDICAL EXEMPTION STATEMENT completed and signed by your physician and submitted to the Student Health Center prior to registration. Students requesting religious exemption regarding NC Immunization Laws, are required to have a RELIGIOUS EXEMPTION STATEMENT completed and submitted to the Student Health Center prior to registration. Read this form carefully and submit all required information as instructed to the health center via fax or mail, or in person.
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North Carolina A&T State University
Sebastian Health Center
1601 E. Market Street
Greensboro, NC 27411
336-334-7880 Office 336-256-2613 Fax
GUIDELINES FOR COMPLETING THE REQUIRED MEDICAL HISTORY PACKET
An Equal Opportunity / Affirmative Action Employer
A Constituent Institution of THE UNIVERSITY OF NORTH CAROLINA SYSTEM
Rev 05/10; 10/10;2/11
The Sebastian Health Center welcomes you to the University. A variety of medical and health services are provided for all registered
students between the hours of 8:00 a.m. and 9:00 p.m. (Monday - Friday).
This Report of Medical History is designed to collect information about your health history and to verify that your immunizations are
in compliance with the N.C. Immunization law. North Carolina state law requires all undergraduate and graduate students taking
4 hours or more on campus to provide documented proof of the required immunizations before registering for classes.
These forms [“A” Report of Medical History, “B” Family & Personal Health History, “C” Immunization Record, “D” Physical
Examination (Required for Special Groups), “E” Meningococcal Vaccine Acknowledgement, and “F” HIPAA Acknowledgment]
must be on file with the Student Health Center prior to May 15th
for fall registration and December 1st for spring registration. If
you are admitted to the university after the above dates, please return your information before your scheduled new student orientation
date.
Completion of these forms is required to finalize your acceptance to North Carolina A&T State University.
Enrollment suspension procedures from classes will take place 30 days after registration, until immunizations and requirements
are documented.
Do not complete this form in pencil. Use a black ink ballpoint pen or type.
Attach copies of immunization records obtained from high school, military service and medical facilities,
that may be used towards meeting the immunization requirements. NOTE: RECORDS MUST HAVE AN OFFICIAL
SEAL / STAMP OR PHYSICIAN’S SIGNATURE TO BE VALID.
If you have not received two (2) Measles, Mumps Rubella, you will be required to receive two (2) dosages (an initial dose
and the second dose within (6) weeks).
Give special attention to showing proof of the Tetanus series: 3 doses of DTP / DTaP / Td and a Tetanus
Booster (Tdap) within the last 10 years.
A Physical Examination is recommended. The physical form should be completed by a licensed physician for all
incoming freshmen and transfer students to the University prior to the first day of class.
Special Groups are required to complete the Physical Examination and Sickle Cell Testing. ( Band, ROTC,
Student Athletes, Intramural Sports).
International students are required to provide proof of a negative PPD/Tuberculin skin test within 12 months proceeding
the first day of classes. If your PPD/TB is positive, a chest x-ray may be performed within the United States.
Students requesting medical exemption regarding NC Immunization Laws, are required to have a
MEDICAL EXEMPTION STATEMENT completed and signed by your physician and submitted to the Student Health
Center prior to registration.
Students requesting religious exemption regarding NC Immunization Laws, are required to have a
RELIGIOUS EXEMPTION STATEMENT completed and submitted to the Student Health Center prior to registration.
Read this form carefully and submit all required information as instructed to the health center via fax or
mail, or in person.
North Carolina Agricultural and Technical State University
Sebastian Health Center
New Student Medical History Packet
Checklist
Dear Prospective Aggie:
Welcome to the University! In an effort to assist with medical compliance, we are sending
this correspondence to all new students.
The enclosed Medical History Packet contains information that is vital in completing the NC
Immunization Requirements. North Carolina state law requires all undergraduate and
graduate students taking 4 hours or more on campus to provide documented proof of the
required immunizations before registering for classes.
Please return only the below documents to Sebastian Health Center. The other documents are
for your review and to keep in your files. Please return the enclosed documents via fax / mail
by May 15th
for fall registration and December 1st for spring registration. If you are admitted
to the university after the above dates, please return your information before your scheduled
new student orientation date.
□ Report of Medical History /Family & Personal Health History (2 pages) (Form A / B)
□ Immunization record / a copy of your personal immunization record / card (Form C)
□ A Physical examination is recommended (Must be completed by a Physician, Nurse
Practitioner or Physician Assistant) (Form D)
□ Meningococcal Vaccine Acknowledgement Form (Form E)
□ HIPAA Acknowledgment Form (Form F)
We look forward to servicing your health care needs. Please do not hesitate to contact the
Sebastian Health Center (SHC) at (336) 334-7880 for additional information regarding the
Medical History Packet.
Aggie Pride!
A Land-Grant University and A Constituent Institution of the University of North Carolina
1601 East Market St • Greensboro, NC 27411 • (336) 334-7880• Fax (336) 256-2613
Rev 08/10; 11/10; 2/11
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North Carolina A&T State University
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336-334-7880
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336-256-2613 Fax
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Sebastian Health Center
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Revised 05/08; 3/11
Form A
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Form B
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IMMUNIZATION RECORD
Last Name First Name Middle Name Date of Birth(mo./day/year) Banner ID#
(Child’s Banner ID #) Signature of Parent/Guardian
________________________________
Date
Form E
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North Carolina Agricultural and Technical State UniversitySebastian Health Center
Privacy Policy (HIPAA) Statement
Student Health Services and HIPAA
You are more than likely familiar with a federal law pertaining to health records called “HIPAA”. In fact, you may have received something called a “HIPAA Notice of Privacy Practices” from your family doctor, your health insurance company, or your neighborhood pharmacy.
HIPAA, the Health Insurance Portability and Accountability Act of 1996, is a Federal Regulation dealing with health records. The purpose of the Act is to ensure the privacy and security of Protected Health Information (PHI) with regards to a patient record.
Student Health Services Notice of Privacy Practices
We are required by federal law to maintain the privacy of health information about you called protected health information (PHI). We are also required to provide you notice of our obligation to protect your PHI and to explain our privacy practices. This notice describes how information about you may be used and disclosed to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law and how you can get access to this information. If you have any questions about this notice, contact North Carolina Agricultural and Technical State University Student Health Services (336) 334-7880.
Our Pledge Regarding Medical Information
At North Carolina Agricultural and Technical State University’s Health Center, we are committed to keeping your protected health information (PHI) confidential. The Notice of Health Information Practices describes the personal information we collect, and how and when we use or disclose that information. Disclosure may occur without your authorization for purposes of treatment, judicial or administrative orders, payment, and health care operations. However, Sebastian Health Center will comply with all HIPAA laws as it represents the highest standard available for protection of your confidential health information.
We reserve the right to change our privacy practices and to make any new provisions effective for all protected health information we maintain. If we change our notice, we will post the revised notice in the facility and will have it available upon request. You can receive a copy of the current notice at any time. The effective date is listed just below the title. You will be asked to acknowledge in writing your receipt of this request. We will not use or disclose your health information without your signed authorization, except as described in this notice. All health records are destroyed eight (8) years after the student has left the University.
A Land-Grant University and A Constituent Institution of the University of North Carolina 1601 East Market St • Greensboro, NC 27411 • (336) 334-7880• Fax (336) 256-2613
Rev 6/07; 7/08
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North Carolina Agricultural and Technical State University
Sebastian Health Center
Health Insurance Portability and Accountability Act (HIPAA)
Patient’s Acknowledgment Form
Dear Prospective Aggie:
Welcome to the University! In an effort to assist with medical compliance, we are sending
this correspondence to all new students.
We are required to obtain your specific written authorization to use or disclose your Protected
Health Information for purposes unrelated to treatment, payment, or health care operations.
We also may use and disclose your Protected Health Information to provide you with
information regarding possible alternative treatment options and other health-related benefits
and services that we believe might interest you.
However, there are exceptions to this general rule under which we are permitted or required to
make certain uses and disclosures of such information without your authorization. These
situations include:
Required by the Secretary of Health and Human Services ● Required by Law
Domestic Armed Forces Personnel ● Health Oversight
Judicial and Administrative Proceedings ● Public Health
Coroners, Medical Examiners, and Funeral Directors
I acknowledge that I was provided my personal copy of my Privacy Policy (HIPAA)
statement to read and keep as my own.
_________________________________ ________________________________ Patient Name (Please Print) Print Name of Parent/Responsible Party
____________________________________ _____ / _____/ ____ Signature of Patient/Parent/Responsible Party Date
Patients Date of Birth ___/____/____ Patients Banner ID 950_____________
We look forward to servicing your health care needs. Please do not hesitate to contact the
Sebastian Health Center (SHC) at (336) 334-7880 for additional information.
Aggie Pride!
A Land-Grant University and A Constituent Institution of the University of North Carolina
1601 East Market St • Greensboro, NC 27411 • (336) 334-7880• Fax (336) 256-2613