Health Forms

Central Methodist University requires all students to fill out the following health forms. Insurance and immunization records are also required.


Student's Contact Information










CMU Student Health Care Patient Information

Psychological or Emotional Concerns:
Emergency Contact Information

















Insurance Information
Medical insurance is required for all CMU students. Parents are encouraged to review insurance issues with their student before he/she arrives on campus and to see that the student is given a copy of the insurance card to carry at all times. Should a student need care beyond the scope of the onsite health center, such as x-rays or pharmaceuticals, the student will be responsible for the bill. Every effort will be made to send the student to a facility covered under the student's health coverage plan. For this reason it would be in the student's best interest to have a list of preferred local providers if the coverage extends to the mid-Missouri area.







Immunization Record
Immunization Policy of CMU: All students enrolled at Central Methodist University for the first time must have documented proof of measles immunity, a recent tetanus/diphtheria booster, and complete a questionnaire screening for tuberculosis. This documentation is required prior to class attendance. CMU does not require the hepatitis B or the meningococcal vaccines; however, we strongly encourage students to follow the recommendation of the American College Health Association: "All college students are strongly urged to receive the hepatitis B vaccine, especially high-risk students, i.e. those who are sexually active with more than one sex partner, those who engage in unprotected sex, those who have had another sexually transmitted disease, or those who share needles for injecting drugs (10/94). ACHA recommends all college health services to take a more proactive role in alerting students and their parents about the dangers of meningococcal disease and also strongly recommends college and universities ensure all students have access to a vaccination program for those who want to be vaccinated against the disease (10/97).
A complete vaccination history must be completed and signed by a Health Care Provider or verified by copy of health department or school record. Official record can be mailed to Central Methodist University, C/O Student Health Center, 411 Central Methodist Square, Fayette, MO 65248 or faxed to 660-248-6992.
HIPAA Privacy Act
Authorization for use or disclosure of protected health information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)



This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I direct. I understand that I have the right to revoke this authorization, in writing at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest the claim. I understand my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may be no longer protected by federal or state law.

In the event of a medical need for the undersigned student while he/she is a student at Central Methodist University, I hereby authorize the performance upon said student such medical procedures as may be prescribed by a nurse practitioner or physician licensed to practice medicine.


 
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