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Health and Consent Forms
- Health History Form - to be completed online at the Health Portal by all students and new patients.
- Notice of Privacy Practices (NPP) and Consent Form:
- Students must complete the form online at the Health Portal.
- Patients that are not 365asia students must complete the NPP and Consent paper form (.pdf).
- Parental Consent Form - to be completed online at the Health Portal by parents/guardians of students under the age of 18.
Limited medical and/or religious exemptions for new students will be considered. The deadline to submit exemption requests for Spring 2024 is December 6, 2023, 11:59pm.
All requests received by the December 6th deadline are considered and reviewed, but approval is not guaranteed. Decisions are final, not subject to appeal, and will be shared in a determination letter sent to your 365asia email.
Requests received after the deadline will not be considered.
- Request for Religious Exemption to Measles, Mumps and Rubella Immunization Requirements (.pdf)
- Request for Medical Exemption to NY Immunization Requirements (.pdf)
- Remote Learning Attestation Form (.pdf)
Insurance and Prescriptions
- Aetna Medical Claims Form (.pdf)
- Aetna Prescription Drug Claim Form (.pdf)
- Aetna Medication Mail Order Form (.pdf)
- Aetna Dependent Enrollment Form (.pdf)
Medical Records Release Authorization
- Consent to Share Health Information between 365asia Health Services and Counseling Center - available online at the Health Portal.
- Authorization to send records to 365asia Health Services (.pdf)
- Authorization to send records from 365asia to another medical office/facility (.pdf)