Please return this form to:
Gannett Health Services
110 Ho Plaza
Ithaca, NY 14853-3101
For information or assistance:
Faculty, Staff, Dependent of Enrolled Student
Health History Form
Welcome to Gannett Health Services. Known as a primary care facility for the health needs of students, Gannett offers a range of services to Cornell employees
and eligible dependents of enrolled students. Gannett is accredited by the Accreditation Association for Ambulatory Health Care.
All medical care and counseling at Gannett is conﬁdential. Health care records are completely separate from all other university records. Gannett Health Services
staff confer with one another as needed to provide integrated care for you; in the event of your treatment at Cayuga Medical Center or another hospital, the
hospital and Gannett will share relevant health information for continuity of care. Otherwise, Gannett will not release any information about you without your written
permission, except as authorized or required by law, or in our judgment as necessary to protect you or others from a serious threat to health or safety.
Gannett uses an electronic health records system, which provides a web portal (myGannett) to facilitate secure communication with our established patients.
Part ONe: IdeNtIFIcatION aNd PrIvacY
Status ⃞ Faculty member ⃞ Staff member ⃞ Dependent of enrolled student (specify) ________________________________________________________________________
Name _________________________________________________________________________ Date of Birth
(mm-dd-yyyy) __________________________ Gender________________________
(last, ﬁrst, middle)
Cornell ID# _________________________________________________________________________________ Cornell Net ID _______________________________________________________
Street or P.O. Box
City State/Province Zip or Postal Code
Phone Numbers Home _______________________________________ Cell _______________________________________ Work _______________________________________
HealtH INSuraNce INFOrmatION
Subscriber Name ____________________________________________________________________________ Relationship _________________________________________________________
Name of Insurance Company ___________________________________________________________________ Policy # _____________________________________________________________
Address of Insurance Company _____________________________________________________________________________________________________________________________________
Gannett participates with a limited number of insurance plans. Learn more about paying for health care at Gannett: www.gannett.cornell.edu/access/fees
PerSON tO NOtIFY IN caSe OF emerGeNcY
Name ______________________________________________________________________________________ Home phone ________________________________________________________
Relationship ________________________________________________________________________________ Work or cell phone __________________________________________________
Gannett has a long-standing commitment to the rights and privacy of its patients and clients. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires all health-
care providers to inform patients/clients of their Notice of Privacy Practices. It describes our policy and the ways in which we use and protect your personal health information.
I acknowledge that I have been given the opportunity to read Gannett Health Services’ Notice of Privacy Practices either on paper or at www.gannett.cornell.edu.
☛ Signature of patient _______________________________________________________________________________ Date (mm-dd-yyyy) __________________________________________
I consent to have Gannett Health Services use and disclose my protected health information for payment, treatment, and health-care operations purposes. My protected health
information means health, billing, and demographic information about me, collected from me, and created or received by Gannett Health Services. In the event that Gannett Health
Services participates with my health insurance, I authorize the payment of beneﬁts to Gannett Health Services.
☛ Signature of patient ___________________________________________________________________________________________________________________________________________
PermISSION tO treat Requires signature of parent/guardian of student under the age of 18.
I give my permission for my daughter/son/ward to receive heath care from Gannett Heath Services and Cayuga Medical Center (and, if necessary, ambulance services) in the event of
an injury or illness. I understand that I will be responsible for all charges for health services provided by Gannett Health Services and by off-campus providers. I acknowledge that I have
been made aware of Gannett’s Notice of Privacy Practices, which can be reviewed at www.gannett.cornell.edu.
☛ Signature of parent/guardian _______________________________________________________________________ Date (mm-dd-yyyy) __________________________________________