1845 Fairmount
Wichita, KS 67260-0092
(316) 978-4792 Fax: (316) 978-3517
Last First Middle Name
Date of Birth: myWSU ID#
I hereby authorize:
Name Telephone Number
Address Fax Number
to release the protected health information indicated below to:
Name Telephone Number
Address Fax Number
Requested Information
[NOTE: You will be charged .10 per one-sided page for paper records plus a $5.00 staff time charge.
If you request your records be faxed, there is a $5.00 fax charge. You understand that forwarding
information by telefacsimile (“fax”) transmission is not a secure form of disclosure. By signing this
authorization, you acknowledge this uncertainty and confirm the fax number you are providing is in
fact the correct one for the designated re cipient.]
Billing Records Lab Reports Pathology Reports Radiology Reports
Physician/Nurse Notes Other: Please Specify:
Psychological Records which may contain information on intake/ assessment/counseling/treatment/
diagnosis (this may include records marked as “Sensitive”).
Information created or received from other providers (Specify which information, provider(s) or all”).
Entire designated record set
Purpose of the Requested Use or Disclosure
The purpose of the use or disclosure is: at the request for the patient or other
[Indicate specific reason.]
Important Information:
The information authorized for release may include records which indicate: the presence of a
communicable or venereal disease including, but not limited to, Hepatitis, Syphilis, Gonorrhea,
Chlamydia, Human Immunodeficiency Virus (HIV), Acquired Immune Deficiency Syndrome (AIDS)
and/or Psychological Records which may contain information on intake/ assessment/counseling/
treatment/diagnosis (this may include records marked as “Sensitive”.)
Please allow a minimum of 48 to 72 hours for records request to be processed by Student Health Services.
Student Health Services will accept a telefacsimile (“fax”) transmission of this authorization provided it is
accompanied by a copy of photo identification of the patient or legal representative* OR the authorization has
been signed in front of a notary public.
By signing below, I certify that I understand that:
1. Unless I revoke this authorization earlier, it will expire one year from the date of my signature.
2. I may refuse to sign this authorization. My refusal will not affect my ability to obtain treatment.
3. If the persons or entities authorized to receive the information above are not health care providers or
alth plans covered by federal he alth privacy laws, they may re-disclose the information and tho
aws would no longer protect the disclosed health information
4. Once I sign this authorization, Student Health Services can rely on it until I revoke it or, if I have not
revoked it, until it expires. I can revoke this authorization by delivering a dated and signed letter to o
inic at 1845 Fairmount, Steve Clark YMCA, Wichita, Kansas 67260-0092
Signature: ______________________________________
(Patient or Legal Representative)
Telephone number:
Capacity of Legal Representative (if applicable)*:
*May be requested to provide verification of representative status.
Wichita State University Privacy Officer:
Misha Jacob-Warren
Deputy General Counsel
Privacy and Compliance Officer
Wichita State University
1845 Fairmount
Wichita, KS 67260-0205
HIPAA Document
Retain for six (6) years
Office Use Only:
Payment Due: Photo ID Checked:
Date Records Sent: Processed by:
Updated 06/20
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