The following forms may be needed when seeking support through Student Health and Counseling:
Request Medical Records
Please fill out the request form in its entirety, including the special records section and chose one way to have them sent to you. If a form is not completely filled out, we will need to contact you which may delay the processing of your request. Please allow two weeks for records to be sent.
Return from Leave of Absence
If you have taken a Leave of Absence as a result of a medical or mental health concern and are ready to return to academics, please fill out this form. The Student Health and Counseling team will work in conjunction with your advising offices, as well as other offices on campus, to evaluate and determine what additional support may be required for a smooth transition to campus.
Your home school(s) will manage your return from leave in collaboration with university support services. You should consult with the appropriate advising office(s) about your return process.
Counseling: Release of Information
Please complete this form so that Student Health and Counseling may share information about your counseling treatment with a designated individual (for example, an advisor, your parents, or a coach).
Forms for PSIP (Penn Student Insurance Plan)
- Aetna Claim Form
- Aetna Prescription Drug Claim Form
- Aetna Prescription Home Delivery Order Form (English)
- Aetna Prescription Home Delivery Order Form (Spanish)
Immunization Requirement Forms
Visit the Immunization Requirements page for current forms and submission instructions.