Forms
Many of our most highly used forms are available for you to complete before your appointment. It is not mandatory that these forms are completed in advance. It is simply a way to speed up your visit, as we know students are busy!
Authorization for Release of Healthcare Information (Medical Records Request)
Consent for Services and Communication Form
Iowa State University Notice of Privacy Practice for Patients Form
Sliding Fee Discount Program Application
Consent for Verbal Communication
Revocation of Authorization of Release of Healthcare Information or Consent for Verbal Communication
Submit forms to the Medical Records Department at shcreco@iastate.edu, by fax at 515-292-9135, or by mail by addressing the from to Medical Records, 2647 Union Drive, Iowa State University, Ames, IA 50011-2029.
Click here for more information on requesting your medical records.
Job Shadow Application for High School and College Students. Please complete and email to cyclonehealth@iastate.edu
Policies
Iowa State University Thielen Student Health Center is governed by the policies of Iowa State University. Although there are numerous policies that apply to the health center, there are a few that are often referenced and therefore called out below.
- Student Health Fee
- Class Excuse Policy
- Sliding Fee Discount Policy
- Right to Receive Good Faith Cost Estimate
- Protection from Surprise Medical Bills
Patient Rights
Each patient has the right to:
- Ask questions about my treatment.
- Choose among Thielen's healthcare providers and change providers, if available.
- Be informed about my diagnosis, evaluation, treatment options and prognosis; participate in healthcare decisions except when the participation is contraindicated for medical reasons.
- Continuity of healthcare between Thielen, hometown, and consulting healthcare provider.
- Request a second opinion from a healthcare provider or mental health professional.
- Appropriate privacy and, if requested, a chaperone.
- Information about services provided, my eligibility for those services and fees and payment options.
- Information about how to seek care after hours and in emergencies.
- Private, confidential, and secure medical records.
- Information about the credentials of Thielen healthcare providers and consultants.
- Submit grievances regarding treatment or care that is, or fails to be, furnished.
- Treatment with respect, consideration, dignity, and without discrimination or bias based on the basis of protected class status.
- Terminate treatment at any time.
- Right to receive a cost estimate
- Protection from surprise medical bills