CCAC-SO-20SP
COMMUNITY COLLEGE OF ALLEGHENY COUNTY
Supportive Services Supportive Services Supportive Services Supportive Services
Allegheny Campus Boyce Campus North Campus South Campus
808 Ridge Avenue 595 Beatty Road 8701 Perry Highway 1750 Clairton Rd
Pittsburgh, PA 15212 Monroeville, PA 15146 Pittsburgh, PA 15237 West Mifflin, PA 15122
OUR GOAL IS YOUR SUCCESS.
Ph: 412.237.4612 Ph: 724.325.6604 Ph: 412.369.3686 Ph: 412.469.6215
Fax: 412.237.2721 Fax: 724.325.6733 Fax: 412.369.3661 Fax: 412.469.6357
I hereby authorize the Community College of Allegheny County’s Office of Supportive Services to release any and all records and
information which they may have concerning me to the person/ organization named below. It is my understanding that the information
will be released in support of my enrollment as a student at the Community College of Allegheny County. I understand that this
authorization is voluntary and that I may be selective in to whom and what information is disclosed. However, I am also aware that
personal information relating to medical and mental health treatment may be disclosed.
Student Name: _____________________________________________________________ID#:___________________________
Current Address: _________________________________________ Birth Date: _________________________________________
Home Phone: __________________________ Mobile Phone: ____________________ Email: ____________________________
Information to be released:
Educational/Academic
Medical
Mental Health
Intake Documents
Employment/Vocational
Other
Please DO NOT disclose the following Information:
This information may be released for the purpose of:
Determining appropriate academic accommodations
Coordination of treatment
Other (please specify)
Name and address of the person(s)/organization(s) to whom the release is to be made:
NAME
TITLE
ORGANIZATION
TYPE
ADDRESS
RELATIONSHIP TO STUDENT:
CITY
ZIP CODE
PHONE
AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION
CCAC-SO-20SP
I have been informed of the Community College of Allegheny County’s Office of Supportive Services policies regarding
confidentiality and the release of my personal information. I understand that I may inspect the information disclosed under
this authorization and that I may receive a copy of this signed authorization form upon request. I understand that this
authorization may be revoked in writing to the Office of Supportive Services at any time, except to the extent that action has
already been taken in reliance on this authorization.
I hereby release the Community College of Allegheny County and its employees and agent from any liability arising from the
release to the parties designated herein of the information that the Office of Supportive Services is herein authorized to
release.
I understand that this authorization shall automatically expire one (1) year from the date of signature unless indicated
otherwise below:
Duration of Authorization:
Notice to Student:
Your signature below indicates that you understand the Community College of Allegheny County’s Office of Supportive
Services is not a covered entity under the HIPPA Federal Privacy Regulations and is, consequently, not subject to those
regulations.
Printed Name of Student:
Student Signature:
Date:
Printed Name of Legal Representative*:
Signature of Legal Representative:
Date:
* A copy of the personal representative’s legal authority to act on behalf of the student is attached
Indefinitely until revoked by me, in writing.
Date of authorization
Other (please specify)
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