A.H. Ray Health Center at WSSU

Forms

Authorization For Release of Information: Use this form if you are requesting Student Health Services to release health information or immunizations to you, another health practitioner or hospital. Please note that immunizations are free of charge.  If you are no longer a student and requesting medical records, there may be a charge for retrieval of records from storage. Please see the Medical Record Retrieval Fee form, complete form and send copy of photo ID. (Please scan copy of ID prior to faxing as faxing it directly is unreadable). Please contact Cashiers office for mode of payment that may be used.

Records Request Form: Use this form if you are requesting records from another physician or physician's practice, hospital or clinic to be sent to the A.H. Ray Student Health Center.

Medical Record Retrieval Fees: Use this form to have records retrieved from storage and there is a charge.

Winston-Salem State University

601 S. Martin Luther King Jr. Drive

Winston-Salem, NC 27110

Phone: (336) 750-2000



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