Important Documents

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Health Insurance information

file-outline Ithaca College MVP Health Care insurance brochure - ICMVPSOB0 2420.pdf (1.34 MB)

Summary of Benefits: Ithaca College MVP Health Care plan for 2020-2021 school year.

Health Certification Forms for NEW STUDENTS

file-outline Immunization Form - required - IMMUNIZATION FORM.pdf (1.05 MB)

Immunization health form for Health Certification requirements

file-outline Meningitis Disease Law information - Meningitisletter_1.pdf (73.3 KB)

Meningitis Disease Law information. Read details about requirements for meningitis vaccination in the college setting.

file-outline Tuberculosis assessment form - required - TB FORM.pdf (1 MB)

Tuberculosis assessment form. 

file-outline Required Forms for Minors - MINOR FORM.pdf (1.02 MB)

Contains three forms. Consent for Treatment of a Minor, Notice of Privacy Practices Receipt, Meningococcal Meningitis Vaccination response form.

file-outline Immunization consent form for MINORS - ImmunConsent_0.pdf (45.49 KB)

If the student is under 18, this form must be filled out by a parent or guardian. Without this form the Health Center is unable to administer the immunization to a minor. 

file-outline Physical Form - PE FORM.pdf (396.14 KB)

IC Physical form

file-outline Meningitis Response Form - MENINGITIS FORM 5.17.23 (1) (1).pdf (206.5 KB)
file-outline Notice of Privacy Practices Form - Notice of Privacy Practice form.pdf (490.7 KB)

Notice of Privacy Practices Form

file-outline Verbal Communication Release Form - Universal IC Roi.pdf (221.96 KB)

Business Office Forms

file-outline Handicap Parking Permit DMV form - DMV6641.pdf (122.74 KB)

Handicap Parking Permit DMV form

file-outline Athletic Injury Form NCAA - AthleticInjuryClaim.pdf (53.43 KB)

Participating in NCAA sport and are injured? Athletic Injury Form NCAA

file-outline Release of Information Form - CHS-Release-Form-09_12_2021.pdf (161.21 KB)

Release of Information Form for Medical Records

file-outline Complaint Form - PatientComplaints.pdf (376.75 KB)

Have a comment or complaint? Please use this form.

file-outline Health Center Informed Consent for Telehealth - Health Center Informed Consent for Telehealth_4-24-2020.pdf (383.9 KB)
file-outline Notice of privacy practices - Notice of privacy practices HC.pdf (33.88 KB)
file-outline Pharmacy and Release of Medication Authorization - Pharmacy Form.pdf (112.03 KB)
file-outline Medication Management for Mental Health Concerns - Medication Management for Mental Health Concerns.pdf (449.82 KB)