Forms, Fees & Billing

Adobe Reader: You will need Acrobat Reader to view some of the forms below. Click here if you need to download Acrobat Reader.

Traditional Signatures: For documents that require a traditional/physical signature on a document (Ex. Release of Information (ROI) Form), follow the Adobe Acrobat Reader - Signature Instructions.  

Smart phones: If you are completing the form and using a smart phone device, please follow the Smart Phone Instructions.

Form Submission: All forms being submitted must be - attached directly to an email, faxed, sent by mail or dropped off during open hours.

If you are submitting the Release of Information Form, please see the content block below for more information. 


 

PSU Vaccine Requirements

COVID-19 Vaccine Requirement 

Visit Banweb to confirm you have been vaccinated. If you are requesting an exemption, you will need to complete the form and submit the form to SHAC for processing.

All forms being submitted must be - attached directly to an email (vaccines@pdx.edu) , faxed on white paper only (503.725.5812), sent by mail (Measles, PO Box 751, Portland, OR 97201) or dropped off during open hours.

Measles Vaccine Requirement

PSU Student Measles Vaccines Requirement Form: You will need to complete the form and submit the form to SHAC for processing.

All forms being submitted must be - attached directly to an email (vaccines@pdx.edu) , faxed on white paper only (503.725.5812), sent by mail (Measles, PO Box 751, Portland, OR 97201) or dropped off during open hours.

Release of Information (ROI): Health & Counseling

Looking to obtain your health records or send them to a new provider? 

1. Current and former Portland State University students can request their health records. 2. Filling out one Authorization ROI form covers the release of both health and mental health records. 3. Fill out one form for each provider receiving the records. 4. If you plan to self release your mental health records, an appointment needs to be made with a SHAC provider. 5. Health & Counseling Services records are only kept on file for 7 years from the last date of service. 6. You may revoke this authorization in writing at any time.

Signatures: The signature on this form must follow the Adobe Acrobat Reader - Signature Instructions. These are the only digital signatures that will be accepted.

Form Submission: You can email, fax, hand deliver (during open hours) or upload it directly to SHAC through the Patient Portal. Once in the Patient Portal, click on 'Message' on the left-hand side, and then choose 'New Message'. Then you will choose 'Upload forms and medical records'. 

PSU Measles Vaccine Requirement

You will need to complete the form and submit the form to SHAC for processing.

Form Submission: All forms being submitted must be - attached directly to an email (measles@pdx.edu) , faxed on white paper only (503.725.5812), sent by mail (Measles, PO Box 751, Portland, OR 97201) or dropped off during open hours.

Release of Information: Health & Counseling

Looking to obtain your health records or send them to a new provider? 

The signature on this form must follow the Adobe Acrobat Reader - Signature Instructions. These are the only digital signatures that will be accepted.

Student Health Insurance - FERPA

FERPA Release Form: Please note, this FERPA Release Form pertains only to the PSU Student Health Insurance Plan and does not include the release of any protected health information.

Student Health Insurance - Waiver Deadline Appeal

The deadline to waive the PSU Student Health Insurance Plan is midnight on Sunday of the second week of each term. This is also the last day to drop a course without financial penalty (see Academic Calendar). If a student failed to complete a waiver application before the deadline, a Missed Waiver Deadline Appeal Form can be submitted for consideration. For more information on Missed Waiver Appeal due dates and criteria, please visit the Missed Waiver Appeal information page.  

Fall 20': 12/4/20 | Winter '21: 3/12/21 | Spring '21: 6/4/21 | Summer '21: 9/3/21

Student Health Insurance - Request for Consideration 

This form is only to be used for students who completed an insurance waiver and it was denied for either not meeting
university criteria OR was audited and found not to meet university criteria. The PSU Student Health Insurance Plan Request for Consideration form must be fully completed and received by the SHAC Insurance Team within ten (10) business days following the PSU Student Health Insurance Waiver Deadline.

Counseling Services - Consent for Treatment

This document is an introduction to our agency and procedures. If you have questions after reading it, please ask them during your initial consultation.

Health Services: Masculinization Therapy Consent Form

This form refers to the use of testosterone by persons in the female-to-male spectrum who wish to become masculine to reduce gender dysphoria and facilitate a more masculine gender presentation. While there are risks associated with taking testosterone, when appropriately prescribed it can greatly improve mental health and quality of life. 

Health Services: Feminization Therapy Consent Form

This form refers to the use of estrogen and/or androgen antagonists (sometimes called “anti-androgens” or “androgen blockers”) by persons in the male-to-female spectrum who wish to become feminized to reduce gender dysphoria and facilitate a more feminine gender presentation. While there are risks associated with taking feminizing medications, when appropriately prescribed they can greatly improve mental health and quality of life. 

Dental: Release of Information

If you need dental records to be released to or discussed with an outside provider for continuity of care, or another entity, complete the Release of Information form. There is a charge for this service.

Flu Shots at SHAC

Flu Vaccine Consent Form

Have an appointment scheduled for a flu shot at SHAC? Fill out the Flu Vaccine Consent Form before arriving for your appointment. 

Hands typing on a laptop computer.

Health Records

Records are released free of charge for continued care and for self-release purposes.

Contact: Susan Martindale, SHAC Health Information Coordinator
Phone: 503.725.2557
Fax: 503.725.5812

Health Services Fees:

Office Visits: $0 - Office visits are covered by the Student Health Fee 
Acupuncture: $10 for 30 minute group session; $150 for one hour individual session
Late Cancellation or No-Show Fee: $0
Additional Costs: Durable Medical Equipment, Immunizations, X-rays, etc.
Summer Office Visits: Summer charges will apply for students taking less than 5 credit hours during summer term.
 

Counseling Services:

Office Visits: $0 Office visits are covered by the Student Health Fee 
Career Assessment: $62-$108
Learning Disability Assessment: $625
Late Cancellation or No-Show Fee: $0
Summer Office Visits: Summer charges will apply for students taking less than 5 credit hours during summer term.

Dental Services:

Services and costs can be found on the Dental Services website. Dental Services charges are billed to a student’s PSU account. However, there are some high-cost procedures which may require payment upfront. Call Dental Services at 503.725.2611 for more information.

Loose dollar bills in a pile.

Health Services Most Common Expenses

Additional Costs

This document provides you with an overview of additional costs for SHAC services such as durable medical equipment, immunizations and injections, procedures, labs, medications administered at SHAC, and more.

Billing Information Overview

The Student Health Fee covers most Medical and Counseling Services at SHAC. However, there are some services that incur an additional cost. For students with private insurance (i.e. are not on the PSU Student Health Insurance Plan) these charges are billed to the student’s PSU account. Please note that charges can take up to a month to post onto the student account. The student can request a statement from SHAC itemizing the billable services received, and also the necessary information an insurance company needs to process a claim. The student’s insurer will decide whether the expense is covered and reimbursed.

Students with the PSU Student Health Insurance Plan may also have some charges billed to their student account such as: exclusions, dental services, and some labs. 

Requesting a Statement of Services Received

To request a statement of services received in SHAC Health Services or Counseling Services to submit to a private insurer, log-on to the Patient Portal using your ODIN login and password, and follow these steps:*

  • Verify your date of birth. 
  • Click on the box with three lines in it found in the upper lefthand corner (the "hamburger" box). 
  • Select Account Summary. 
  • You will see a history of any visit to Health or Counseling Services. There is an option to Print for each date of service. 
  • If you have any questions, difficulties, or do not see what you need, send a confidential secure message using the Patient Portal. From the main menu, select Messages. Then select the Communication Option "I have a billing question."
  • *Portland-based University of Oregon students can access the Patient Portal. If you are a Portland-based University of Oregon student who has received services at SHAC and wish to receive a statement to submit to your private insurer, visit the Patient Portal to view your Account Summary. If you’re having difficulty logging into the Patient Portal, please call 503.725.2800.

PacificSource claims for possible reimbursement

Please note that claim forms are not required. To submit a claim, make a copy of the bill/receipt, write your name, medical ID number, PSU ID number, and what university you attend directly on the bill/receipt.

Submit to:
PacificSource
P.O. Box 7068
Springfield, OR 97475

For questions regarding claims, coverage and finding in-network providers, please contact PacificSource at (855) 274-9814, or visit PacificSource.