Office of the Registrar - Cape Cod Community College -
Student Immunization Records
2240 Iyannough Road, West Barnstable, MA 02668
1-508-362-2131 Ext. 4331 / Fax 508-375-4039 /
sthompson@capecod.edu
AUTHORIZATION TO RELEASE MEDICAL INFORMATION
Your health information is confidential and protected by state and federal laws. The information you submit is maintained by Cape Cod
Community College Student Immunization Records Office in the strictest confidence. HIPAA regulations prevent us from releasing or discussing
any health information without written consent of the patient, except when there is imminent danger to you or to others, or when required by law.
Last Name:
First Name:
Student ID #:
Other Name(s) (if different from above):
Date of Birth: (mm/dd/yyyy)
SSN:
Phone: Dates of Attendance:
Address: City:
State:
Zip:
Permission is hereby given for Cape Cod Community College Student Immunization Records Office to release
the information specified below from the medical record to:
Telephone:
Fax:
I understand that the information to be released may include information protected by federal and state laws. By my
signature below, I authorize the disclosure and/or discussion of the following checked information:
□Complete Health Record □Immunization Record □Physical Exam □Laboratory Report(s)
METHOD OF RELEASE AUTHORIZED: (Check all that apply)
□ Permission to fax
□ Student/Authorized 3
rd
Party picks up information in person
□ Information sent by mail
□ Verbal / Telephone
THIS AUTHORIZATION IS VALID FOR THE DURATION OF THE ABOVE NAMED STUDENT’S ENROLLMENT
AT CAPE COD COMMUNITY COLLEGE FROM THE DATE OF SIGNATURE. THIS AUTHORIZATION WILL
BECOME NULL AND VOID UPON THE STUDENT’S SEPARATION FROM THE COLLEGE.
I understand that I may revoke this consent in writing at any time, except to the extent that action has already been
taken in response to this authorization. I also release the Cape Cod Community College Student Immunization
Records Office from any liability or legal responsibility in connection with the release of the above information.
Student
Signature:
_
Date:
For Student Immunization Records Office Use:
Date
Completed:
#
of
Pages
Copied:
_
Staff
Initials: _
04/02/2012 slg 6/27/16 smt
click to sign
signature
click to edit
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