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Medical Records Request

Request for
School of Nursing Medical (Health) Information

If you are requesting copies of health related information, such as your Immunization history, etc. The following will help walk you through that process.

1) Requests for school of nursing medical health information must include the following:

  • Date of Request
  • Name
  • Student ID Number or Social Security Number
  • Current mailing address
  • Telephone number
  • Date of birth
  • Date of graduation or last attendance
  • Specific health information to be sent
  • Complete address of where transcript is to be mailed
  • Signature and Date

2) Download form

Download a Request for Medical Information Form in either Word or PDF format.

Please Note: because this is protected confidential information, the School WILL NOT FAX any part of your requested record information to a Third Party. All requested information must be sent to a specific person.

3) If you wish to mail the form, please mail it to:

Health Officer
St. Elizabeth School of Nursing
1501 Hartford Street
Lafayette, IN 47904

Health information records are usually mailed the same day the written and signed Request for Medical Information Form is received, however please allow at least three (3) business days in order to process the request.