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Western Kentucky University

WKU Health Services : Patient Forms

WKU Health Services Patient Forms

Please read the forms below and then print and complete the ones indicated. You will want to bring those completed forms with you on your first visit to WKU Health Services. Doing so will allow us to record your personal information more quickly and shorten the time spent waiting to see one of our providers.

WKU Health Services New Patient Paperwork: (complete, print, and sign) You should use this document to record your contact information and your basic medical and health history.

Authorization to Release Records: (complete, print, and sign)

Medical Treatment to Release for Minors: (complete, print, and sign)

WKU Health Services Patient's Right and Responsibilities: (read and/or print) This document outlines all of your rights, including those protected under HIPAA, and responsibilities as a patient at WKU Health Services.

WKU Health Services Patient's Right to Privacy: (read and/or print) This document outlines all of your rights, including those protected under HIPAA, and responsibilities as a patient at WKU Health Services.

HIPAA Notice of Privacy Policies: (read and/or print) This document describes how information about you may be used and disclosed and how you can get access to the information.

Per HIPAA laws, you must be given a "Notice of Privacy Policies" statement describing how healthcare providers are allowed to use the information from your personal medical file, including when and who they can give the information to. If you are a regular patient at a facility, you only have to sign the HIPAA paperwork once. It will then become part of your permanent file.

If you feel your personal privacy rights have been violated, you may contact WKUHS Patient Services Coordinator at (270) 745-5113 or WKUHS Business Office Manager at (270) 745-2280.

**Patients arriving more than 10 minutes late for an appointment, may be asked to reschedule their visit.**

Note: documents in Portable Document Format (PDF) require Adobe Acrobat Reader 5.0 or higher to view,
download Adobe Acrobat Reader.

Note: documents in Excel format (XLS) require Microsoft Viewer,
download excel.

Note: documents in Word format (DOC) require Microsoft Viewer,
download word.

Note: documents in Powerpoint format (PPT) require Microsoft Viewer,
download powerpoint.

Note: documents in Quicktime Movie format [MOV] require Apple Quicktime,
download quicktime.

 
 Last Modified 9/24/14