Health Forms

Health Records and Forms 

In order to respond effectively to your health needs while attending Siena College and to comply with New York State Public Health Law, you and your health care provider must complete a Health Record and Immunization Record.

Incoming freshmen: Your Health Record and Immunization Record must be submitted by June 21.  We recognize that some college entrance physicals may not be scheduled by this date. In this case, you must forward a completed Immunization Record signed and stamped by your physician office by June 21. The health record may follow once it is completed, as long as it is submitted prior to the start of classes.

Transfer students must submit these two health forms prior to the start of classes.

Please include a photocopy (front and back) of your health insurance card with your Health Record.

In addition to the Health Record and Immunization Record, the following forms should be completed if you have a special medical need and/or you will not be 18 years old at the time of arrival to campus. These forms should be submitted with your health record prior to the start of classes:

The Consent for Release of Medical Information for Students with Special Health Needs should be submitted if you have any special medical information that you would like shared with the Health Office, the Department of Public Safety and the Dean of Student Affairs to facilitate appropriate emergency care if necessary.

  • The “Consent of Parent or Guardian for Medical Treatment Form” must be signed and notarized if you will be less than 18 years of age at the time of your arrival to campus.

  • The “Authorization for Release of Medical Records to Siena Health Service” is available to assist transfer students in getting your health and immunization records on file at your previous college transferred to our Health Service.  This form should be completed by you and submitted to your previous college.

All full time registered students are required to have health insurance coverage. All full time Siena College students are asked to complete the on-line decision form regarding health insurance coverage at www.cdphp.com/siena beginning June 1, 2014
 
Siena College has contracted with Capital District Physician’s Health Plan (CDPHP) to provide a Student Health Plan for students. The cost for the health plan is $1,161 for the plan year of August 15, 2014-August 14, 2015 and you will be enrolled and the charge placed on your account unless you complete the on-line decision form! 
 
If you presently are covered by another health insurance plan, you may process a waiver to opt out of this plan prior to the deadline of October 1st for the Fall semester. Additional information about the student health plan including the waiver is available at www.cdphp.com/siena beginning on June 1, 2014.
 

Please mail or fax all health forms to:

Office of Health Service
Siena College
MacClosky Townhouse Commons
515 Loudon Road
Loudonville, NY 12211
Fax:(518) 783-2961

If you have any questions, contact Health Services at (518) 783-2554.

HEALTH FORMS