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Forms & Documents - Boynton Health - University of Minnesota
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class="sf-depth-2">STI Testing</a></li><li id="main-menu-link-contentf7b68f2d-f57e-4a30-9a0f-3cb7f6e80b1b" class="sf-depth-2 sf-no-children"><a href="https://boynton.umn.edu/appointments#Telehealth" class="sf-depth-2 sf-external">Telehealth</a></li><li id="main-menu-link-contentfb0d872f-a4f8-4726-9cc0-93973feb2998" class="sf-depth-2 sf-no-children"><a href="https://boynton.umn.edu/boynton-health-tobacco-cessation-coaching" class="sf-depth-2 sf-external">Tobacco Cessation Coaching</a></li><li id="main-menu-link-contente3e45d59-f561-45b3-83e7-5cc2947fd75a" class="sf-depth-2 sf-no-children"><a href="/services/travel-clinic" class="sf-depth-2">Travel Clinic</a></li><li id="main-menu-link-content85366d43-f93e-4b33-9be3-27baecbdfb21" class="sf-depth-2 sf-no-children"><a href="https://boynton.umn.edu/gopher-quick-clinic" title=" Gopher Quick Clinic" class="sf-depth-2 sf-external"> Gopher Quick Clinic</a></li><li id="main-menu-link-contentc56eeb1c-15d3-4b59-9436-5aeb0e5dd593" class="sf-depth-2 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class="sf-depth-2 sf-no-children"><a href="/food-pantry" class="sf-depth-2">Nutritious U Food Pantry</a></li><li id="main-menu-link-content01c97c42-6328-4d7c-96d1-1fef74857dd6" class="sf-depth-2 sf-no-children"><a href="/safersex101" class="sf-depth-2">Safer Sex 101</a></li><li id="main-menu-link-contenta1a54c83-75ff-4743-b550-98f02ca11658" class="sf-depth-2 sf-no-children"><a href="/health-advocates" class="sf-depth-2">Health Advocates</a></li><li id="main-menu-link-content66cfaa44-8659-4fc3-8eaa-6ccfd571a237" class="sf-depth-2 sf-no-children"><a href="/services/mental-health/training" class="sf-depth-2">Mental Health Training</a></li><li id="main-menu-link-contentc6f6999e-bdfe-444c-9e89-f575a608c487" class="sf-depth-2 sf-no-children"><a href="/college-student-health-survey" class="sf-depth-2">College Student Health Survey </a></li><li id="main-menu-link-content6ff86616-1aa5-4c1d-b1dd-77823d792f97" class="sf-depth-2 sf-no-children"><a href="/roc" class="sf-depth-2">Recovery on Campus (ROC)</a></li></ul></li><li id="main-menu-link-content9f35e7bc-53fa-40d3-a7a5-72200ce8d5df" class="sf-depth-1 menuparent"><a href="/" class="sf-depth-1 menuparent" aria-haspopup="true" aria-expanded="false">Information</a><ul><li id="main-menu-link-content06bc75e7-ad7c-4903-966f-6b2d9ac7daae" class="sf-depth-2 sf-no-children"><a href="/why-choose-boynton" class="sf-depth-2">Why Choose Boynton Health?</a></li><li id="main-menu-link-content00517eab-fb8c-4cc5-bcef-b5c0d163f932" class="sf-depth-2 sf-no-children"><a href="/forms-documents" class="sf-depth-2">Forms & Documents</a></li><li id="main-menu-link-content4adc9a0c-9963-457b-8014-d707b2148d2b" class="sf-depth-2 sf-no-children"><a href="/students" class="sf-depth-2">For Students</a></li><li id="main-menu-link-contentb6cddcd9-fedf-46be-a867-a06170df09cf" class="sf-depth-2 sf-no-children"><a href="/international-students" class="sf-depth-2">For International Students</a></li><li 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class="sf-depth-2 sf-no-children"><a href="/shac" class="sf-depth-2">Student Health Advisory Committee</a></li><li id="main-menu-link-content90a17e49-eb58-421b-9cf1-f3b86035d153" class="sf-depth-2 sf-no-children"><a href="/media-communications" class="sf-depth-2">Marketing & Communications</a></li><li id="main-menu-link-content074f764d-8a5d-4862-b8f8-7593d646706b" class="sf-depth-2 sf-no-children"><a href="/information/new-student-guide" class="sf-depth-2">New Student Guide</a></li></ul></li><li id="main-menu-link-content8f478333-1407-4e74-b995-17a5880f901f" class="sf-depth-1 menuparent"><a href="/" class="sf-depth-1 menuparent" aria-haspopup="true" aria-expanded="false">Get Care Now</a><ul><li id="main-menu-link-content91a182af-3889-4a4f-872d-55dc22149c63" class="sf-depth-2 sf-no-children"><a href="/appointments" class="sf-depth-2">Make an Appointment</a></li><li id="main-menu-link-content69dd43e4-ce84-4553-9736-c9c19abed079" class="sf-depth-2 sf-no-children"><a href="/myboynton" class="sf-depth-2">MyBoynton Patient Portal</a></li><li id="main-menu-link-content932fc70f-f666-4703-83c7-4eb7ef538b38" class="sf-depth-2 sf-no-children"><a href="/locations" class="sf-depth-2">Hours & Locations</a></li><li id="main-menu-link-contentf340899a-9ad1-49d5-86dd-d67ee3a10080" class="sf-depth-2 sf-no-children"><a href="/after-hours-care" class="sf-depth-2">After Hours Care</a></li><li id="main-menu-link-content2790c5ff-ee13-41c9-8d0a-031327a54169" class="sf-depth-2 sf-no-children"><a href="/nurse-line" class="sf-depth-2">Nurse Line</a></li><li id="main-menu-link-content5dbcff1f-1e74-4397-87a8-932a983dac9f" class="sf-depth-2 sf-no-children"><a href="/directory" class="sf-depth-2">Staff Directory</a></li></ul></li> </ul> </div> </div> </div> </header> <section id="featured"> <div class="columns"> <div class="region region-featured"> <div data-drupal-messages-fallback class="hidden"></div> </div> </div> </section> <main role="main" class="clearfix"> <a id="main-content" tabindex="-1"></a> <div class="block-page-title-block"> <h1 class="title">Forms and Documents</h1> </div> <section id="content"> <div class="region region-content"> <div id="block-boynton-health-content" data-block-plugin-id="system_main_block" class="block block-system block-system-main-block"> <article id="node-461" class="" about="/forms-documents"> <div class="field field--name-field-components field--type-entity-reference-revisions field--label-hidden field__items"> <div class="field__item"> <div class="paragraph paragraph--type--centered-components paragraph--view-mode--default"> <div class="field field--name-field-centered-component field--type-entity-reference-revisions field--label-hidden field__items"> <div class="field__item"> <div class="paragraph paragraph--type--body-copy paragraph--view-mode--default"> <div class="clearfix text-formatted field field--name-field-body-copy field--type-text-long field--label-hidden field__item"><blockquote><p>Forms and documents used at Boynton Health.</p></blockquote><h2>Medical Records and Billing Forms</h2><ul><li><a href="https://boynton.umn.edu/sites/boynton.umn.edu/files/2024-04/344F1%20Release%20of%20Information%20Form.pdf" target="_blank">Health information release form</a></li><li><a href="https://boynton.umn.edu/sites/boynton.umn.edu/files/2024-10/form_billing_information_release%20%282%29.pdf" target="_blank">Billing information release form</a></li><li><a href="/node/221" target="_blank">Immunization requirements forms and procedures</a></li><li><a href="/sites/boynton.umn.edu/files/2022-12/MIN%20BBPE%20forms%20v.12.5.2022.pdf" target="_blank">Blood borne pathogen exposure procedure and form</a></li></ul><h2>Patient Forms</h2><h3>Dental</h3><p>*These forms are fillable when downloaded to your desktop.</p><ul><li><a href="/sites/boynton.umn.edu/files/2022-07/dental_comm_consent_121420.pdf" target="_blank">Dental Communication Consent</a></li><li><a href="/sites/boynton.umn.edu/files/2022-07/dental_covid_risk_consent_form_121420.pdf" target="_blank">Dental COVID-19 Risk Consent</a></li><li><a href="/sites/boynton.umn.edu/files/2022-09/Dental_MED_HX_9_2022.pdf" target="_blank">Dental Medical History</a></li><li><a href="/sites/boynton.umn.edu/files/2022-07/dental_patient_resp_statement_121420.pdf" target="_blank">Dental Patient Responsibility Statement</a></li></ul><h3>Medical</h3><ul><li><a href="/sites/boynton.umn.edu/files/2024-02/FINAL_Boynton%20Health%20Controlled%20Substance%20Agreement_2_2024.docx%20-%20Kristin%20Verhoeven.pdf" target="_blank" data-entity-type="file" data-entity-uuid="822a9f9a-cd31-450d-b456-a9780a0d3db1" data-entity-substitution="file">Controlled Substance Agreement Form</a></li><li><a href="/sites/boynton.umn.edu/files/2022-07/form-prep-agreement.pdf" target="_blank">PrEP Agreement Form</a></li><li><a href="https://cdn2.hubspot.net/hubfs/377740/Order_Forms/FRM-3006-01-c_F_CologuardTest_HCP-HTO.pdf" target="_blank">Cologuard Order Requisition Form</a></li><li><a href="https://boynton.umn.edu/sites/boynton.umn.edu/files/2023-11/Form-AHS-Immunization-update%2010.pdf" target="_blank">AHS Immunization Form</a></li></ul><h3>Mental Health</h3><ul><li><a href="/sites/boynton.umn.edu/files/2024-02/FINAL_Boynton%20Health%20Controlled%20Substance%20Agreement_2_2024.docx%20-%20Kristin%20Verhoeven.pdf" target="_blank" data-entity-type="file" data-entity-uuid="822a9f9a-cd31-450d-b456-a9780a0d3db1" data-entity-substitution="file">Controlled Substance Agreement Form</a></li><li><a href="https://onestop.umn.edu/sites/onestop.umn.edu/files/forms/OTR174_2024.pdf" target="_blank">Academic Medical/Disability Supplement Form</a></li><li><a href="https://onestop.umn.edu/sites/onestop.umn.edu/files/forms/fa924.pdf" target="_blank">Student Services Fee Assessment Request Form</a></li><li><a href="https://boynton.umn.edu/sites/boynton.umn.edu/files/2024-04/ISSS%20ROI%20Template%202024.pdf" target="_blank">ISSS Health Information Release Form</a></li><li><a href="https://boynton.umn.edu/sites/boynton.umn.edu/files/2024-04/DRC%20ROI%20Template%202024.pdf" target="_blank">DRC Health Information Release Form</a></li></ul><h2>Absence Notes</h2><p>Under the University of Minnesota's Make-up Work for Legitimate Absence Policy, Boynton Health does not provide absence notes. The policy explains what you need to do if you miss class or coursework. Learn more about the <a href="/node/301">absence note policy</a>.</p><p> </p></div> </div> </div> </div> </div> </div> </div> </article> </div> </div> </section> </main> <div class="above-footer-wrap" role="region"> <div class="region region-above-footer"> <div id="block-contactorvisitus" data-block-plugin-id="block_content:82f7c12b-2dcf-49e5-8812-d27c1897bda2" class="block block-block-content block-block-content82f7c12b-2dcf-49e5-8812-d27c1897bda2"> <h2 >Contact or visit us</h2> <div class="above-footer-block one"> <h3 class="title"> </h3> <div class="above-footer-content"> <div class="clearfix text-formatted field field--name-field-block-1-content field--type-text-long field--label-hidden field__item"><h3><a href="/node/456">Appointments</a></h3><p><br><strong>For appointments, call:<br></strong><a href="tel:612-625-3222"><strong>612-625-3222</strong></a></p><p><strong>Nurse line open 24/7:<br></strong><a href="tel:612-625-7900"><strong>612-625-7900</strong></a><strong> </strong></p><p><strong>Crisis line open 24/7:<br></strong><a href="tel:612-301-4673"><strong>612-301-4673</strong></a><strong> </strong></p><p><strong>Need after-hours care?</strong><br><a href="/node/421">See our options</a></p><p><a href="/node/1606"><strong>Parking</strong></a></p></div> </div> </div> <div class="above-footer-block two"> <h3 class="title"> </h3> <div class="above-footer-content"> <div class="clearfix text-formatted field field--name-field-block-2-content field--type-text-long field--label-hidden field__item"><h3><a href="/node/121">East Bank Clinic</a></h3> <p><br /> <strong>Get Directions:</strong><br /> <a target="_blank" href="https://www.google.com/maps/place/Boynton+Health/@44.9721954,-93.2344096,15z/data=!4m5!3m4!1s0x0:0xbe666a9f6216a69b!8m2!3d44.9721954!4d-93.2344096">410 Church St S.E.<br /> Minneapolis, MN</a><br /> <br /> <strong>Clinic Hours:</strong><br /> M, T, W, F | 8:00 am to 4:30 pm<br /> Th | 8:30 am to 4:30 pm<br /> <em>* M, T, W, F | Doors open at 7:45 am</em></p> </div> </div> </div> <div class="above-footer-block three"> <h3 class="title"> </h3> <div class="above-footer-content"> <div class="clearfix text-formatted field field--name-field-block-3-content field--type-text-long field--label-hidden field__item"><h3><a href="/node/126">St. Paul Clinic</a></h3> <p><br /> <strong>Get Directions:</strong><br /> <a target="_blank" href="https://www.google.com/maps/dir//Coffey+Hall,+1420+Eckles+Ave,+St+Paul,+MN+55108/@44.9825953,-93.2543065,13z/data=!4m9!4m8!1m0!1m5!1m1!1s0x52b32c834c6ceaff:0x29d2a1ba7f0c04de!2m2!1d-93.1853812!2d44.9838825!3e0">Coffey Hall<br /> 1420 Eckles Avenue<br /> St. Paul, MN</a><br /> <br /> <strong>Clinic Hours:</strong><br /> M, T, F | 8:00 am to 4:30 pm<br /> <em>*Closed 1:00 pm - 2:00 pm</em></p> </div> </div> </div> <div class="above-footer-block four"> <h3 class="title"> </h3> <div class="above-footer-content"> <div class="clearfix text-formatted field field--name-field-block-4-content field--type-text-long field--label-hidden field__item"><h3><a href="/node/106">West Bank Clinic</a></h3> <p><br /> <strong>Get Directions:</strong><br /> <a target="_blank" href="https://www.google.com/maps/place/O.+Meredith+Wilson+Library/@44.9709111,-93.2456857,17z/data=!3m1!4b1!4m5!3m4!1s0x52b32d41a338fe4b:0xf04cecd4029a51ad!8m2!3d44.9709073!4d-93.2434917">309 19th Ave SE<br /> Wilson Library (4th floor)<br /> Mental Health Only</a><br /> <br /> <strong>Clinic Hours:</strong><br /> M – F | 8:00 am to 4:30 pm</p> </div> </div> </div> </div> </div> </div> <footer id="site-footer" role="contentinfo"> <section class="footer-top"> <div class="region region-footer-top"> <div id="block-footer-2" data-block-plugin-id="block_content:e2a632f6-cb90-4ca8-97f1-a055e8d856ce" class="block block-block-content block-block-contente2a632f6-cb90-4ca8-97f1-a055e8d856ce"> <div class="footer-three-columns-block one"> <h2 class="title"> <div class="field field--name-field-block-1-title field--type-string field--label-hidden field__item">About Boynton Health</div> </h2> <div class="footer-three-columns-content"> <div class="clearfix text-formatted field field--name-field-block-1-content field--type-text-long field--label-hidden field__item"><p>Boynton Health serves students, faculty and staff of the University of Minnesota Twin Cities, providing comprehensive health care with a public health approach to campus well-being.<br /> </p> <ul> <li><a href="/careers">Careers</a></li> <li><a href="/node/1561">Media</a></li> <li><a href="/why-choose-boynton">About Us</a></li> <li><a href="/contact">Contact Us</a></li> <li><a href="/stories">Stories</a></li> <li><a href="/why-choose-boynton#questions">Frequently Asked Questions</a></li> <li><a href="/patient-rights-and-responsibilities">Patient Rights and Responsibilities</a></li> <li><a href="/accreditation">Accreditation</a></li> <li><a href="/compliance-and-quality-assurance">Compliance and Quality Assurance</a></li> <li><a href="https://docs.google.com/spreadsheets/u/0/d/1BI6Q7PGHCcZy_VTD_jSfRVc7aEH9E19N__nvo1UPE0g/pubhtml?urp=gmail_link&gxids=7628">Employee Portal</a></li> </ul> </div> </div> </div> <div class="footer-three-columns-block two"> <h2 class="title"> <div class="field field--name-field-block-2-title field--type-string field--label-hidden field__item">Patient Resources</div> </h2> <div class="footer-three-columns-content"> <div class="clearfix text-formatted field field--name-field-block-2-content field--type-text-long field--label-hidden field__item"><ul><li><a href="/node/431">Patient Portal</a></li><li><a href="/node/461">Forms</a></li><li><a href="/directory">Directory</a></li></ul></div> </div> </div> <div class="footer-three-columns-block three"> <h2 class="title"> <div class="field field--name-field-block-3-title field--type-string field--label-hidden field__item">Connect</div> </h2> <div class="footer-three-columns-content"> <div class="clearfix text-formatted field field--name-field-block-3-content field--type-text-long field--label-hidden field__item"><ul class="social-links"><li><a href="https://www.instagram.com/boyntonhealth"><span class="fontawesome-icon-inline"><span class="fa-instagram fab"> </span></span></a></li><li><a href="https://www.facebook.com/umn.bhs"><span class="fontawesome-icon-inline"><span class="fa-facebook fab"> </span></span></a></li><li><a href="https://twitter.com/boyntonhealth"><span class="fontawesome-icon-inline"><span class="fa-twitter fab"> </span></span></a></li><li><a href="https://www.linkedin.com/company/boyntonhealth"><span class="fontawesome-icon-inline"><span class="fa-linkedin fab"> </span></span></a></li><li><a href="https://www.youtube.com/user/BoyntonHealth/featured"><span class="fontawesome-icon-inline"><span class="fa-youtube fab"> </span></span></a></li></ul><p><strong>Email</strong><br><a href="/cdn-cgi/l/email-protection#86e4eeabf7f3e3f5f2c6f3ebe8a8e3e2f3"><span class="__cf_email__" data-cfemail="8ae8e2a7fbffeff9fecaffe7e4a4efeeff">[email protected]</span></a></p></div> </div> </div> </div> </div> </section> </footer> </div> </div> <!-- Begin UMN Footer --> <footer> <div id="umnhf-f" class="umnhf" role="contentinfo"> <div class="footer-inner"> <nav id="umnhf-f-myu"> <h3 class="umnhf-f-title visually-hidden">For Students, Faculty, and Staff</h3> <ul role="presentation"> <li><a href="http://onestop.umn.edu/">One Stop</a></li> <li><a href="https://www.myu.umn.edu/">MyU <span></span></a></li> </ul> </nav> <div class="footer-logo"></div> <small>© <span id="cdate">2024</span> Regents of the <a href="https://system.umn.edu">University of Minnesota</a>. All rights reserved. <br>The University of Minnesota is an equal opportunity educator and employer. <a href="https://privacy.umn.edu">Privacy Statement</a></small> <!-- Optional last updated link--> <!-- add time tag w datetime attr --> </div> </div> </footer> <!-- End UMN Footer --> <div class="off-canvas-wrapper"><div id="off-canvas"> <ul> <li class="menu-item--ffb4e276-f164-4855-a528-16645735a63d menu-name--main"> <a href="/locations">Locations</a> <ul> <li class="menu-item--_3cf675a-a452-47ca-8a1f-9fa937f3a1c0 menu-name--main"> <a href="/locations/east-bank">East Bank</a> </li> <li class="menu-item--_260579f-f317-468b-b917-6b8ddb0ed3cd menu-name--main"> <a href="/locations/west-bank">West Bank</a> </li> <li class="menu-item--bc53f740-ba21-41e4-87fb-aa3f8b449b56 menu-name--main"> <a href="/locations/stpaul">St. Paul</a> </li> <li class="menu-item--_8cece89-fe4d-47c9-91e9-77ea3a1812f0 menu-name--main"> <a href="/locations/recwell">RecWell</a> </li> <li 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href="/services/eye-care">Eye Clinic & Optical Shop</a> </li> <li class="menu-item--a12d3a6c-17e5-4985-923c-24c85c002f89 menu-name--main"> <a href="/services/gender-care">Gender Care</a> </li> <li class="menu-item--b3ffe19b-ca2d-4fb5-b7a6-e221b21eb566 menu-name--main"> <a href="/services/gynecology">Gynecology</a> </li> <li class="menu-item--_1d7270b-0d5a-416f-9643-2f76778e2e9f menu-name--main"> <a href="/services/mental-health">Mental Health</a> </li> <li class="menu-item--fba680dd-86a6-4ad4-a44b-bcb3c7acac17 menu-name--main"> <a href="/services/nutrition">Nutrition</a> </li> <li class="menu-item--_23e85a5-e514-42d5-a401-72ebc5c29cfa menu-name--main"> <a href="/services/pharmacy">Pharmacy</a> </li> <li class="menu-item--ede4119d-289d-49bf-b273-f2ac663b8d3a menu-name--main"> <a href="/services/physical-therapy">Physical Therapy</a> </li> <li class="menu-item--_a3b559f-1ad7-41ea-82e6-655bc4d8bf45 menu-name--main"> <a href="/services/primary-care">Primary Care</a> </li> <li 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