Health Records and Other Forms

Waiver Forms

Medical Vaccination Exemption Request Form (PDF)

This form is for requesting an exemption from the vaccination requirements for medical reasons. The form must be completed and signed by a licensed Medical person. Upload completed document to the Secure Patient portal for review and verification by Health Center team.

Meningococcal Waiver Form (PDF)

This form is for students under age 21 to provide informed declination of required Meningococcal vaccine (this is not recommended).

Religious Exemption Form

This electronic submission form is for requesting an exemption from the vaccination requirements for religious reasons. The form will be reviewed by a team of Brandeis administrators. The student will receive notification of approval or denial via your Brandeis email.

HIPAA Authorization for Release of Patient Information and Medical Records (PDF)

This form is to request copies of your medical records which are kept at Brandeis Health Center for 10 years. It can also be used (when signed by an adult student) to allow us to speak to a designated person who calls us for information about the student's health.

Accessibility and Accommodation Forms

The Health Center does not directly provide accessibility accommodations for students but provides, as needed, a medical review and support for clarifying medically required accessibility and accommodation needs.

Housing Accommodation Application

The process for requesting and acquiring housing accommodations is managed by the Department of Community Living (DCL) with support from the Brandeis Housing Accommodation Review Committee. The DCL Accommodations page provides information on the process for requesting accommodations, as well as important timelines. Please visit the webpage for more details.

Parking and Dietary Accommodations

The process for Parking and Dietary Accommodation requests is managed through Student Accessibility Support with the Parking and Dietary Review Committees. Please see its site for more information on these processes.