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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 Patient Medical History Form: (complete, print, and sign) You should use this document to record your contact information and your basic medical and health history.
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.
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.
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.
Acknowledgement of Receipt of HIPAA Privacy Practices: (complete, print, and sign) This document is kept on file to verify that WKU Health Services provided you with a copy of its HIPAA Notice of Privacy Policies.