AUTHORIZATION TO RELEASE AND DISCLOSE PROTECTED HEALTH INFORMATION
Client/Patient Information
Name:
Date of Birth:
Student ID:
Purpose of Disclosure:
(Examples: Coordination of Care, Evaluation, Academic Support, Documentation, Referral, Personal)
I Authorize
(Who has the information you
want released)
*Must be filled out completely*
Agency/Name:
Phone:
Fax:
City:
State:
Zip:
Receiving Party
(Where do you want the
information to go)
*Must be filled out completely
Agency/Name:
Phone:
Fax:
City:
State:
Zip:
Counseling & Psychological
Services
Information to be Released
(Check all appropriate boxes)
Evaluations & Progress Notes
Verification of Treatment
Entire Counseling Records
Records Dated:
Health & Psychiatric Services
Information to be Released
(Check all appropriate boxes)
Entire Health Record
Psychiatric Notes
Immunization Records
X-Ray Reports
Lab Reports/Test
Verification of Treatment
Records Dated:
This authorization lasts for one year after the date you sign it unless you enter a different date or expiration here:
This authorization may be canceled (revoked) in writing at any time. A cancelation will not change releases that happened before the cancelation was submitted.
Student Health & Counseling Services (SHCS) records may include records that it received from other organizations. If these records have been used by SHCS and
filed in the record SHCS maintains about you, these records may be released with your SHCS records.
SHCS cannot prevent disclosure of your information by the person or organization who receives your records under this authorization, and that information may
not be covered by state and federal privacy protections after it is released. By signing this authorization, you release SHCS from any and all liability resulting from a
disclosure by the release.
Your signature indicates that you have read and understand this form, and authorize release of your information as described above.
Signature (Patient/Client)
Date
Signature (Parent/Guardian) If Applicable
Date
SHCS Authorization to Release & Disclose Protected Health Information | V2.2018
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