Fillable Authorization To Release or Obtain Health Records (Springfield Technical Community College)

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Authorization To Release or Obtain Health Records (Springfield Technical Community College)

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The Authorization To Release or Obtain Health Records (Springfield Technical Community College) form is 1 page long and contains:

  • 1 signature
  • 8 check-boxes
  • 13 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Springfield Technical Community College

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1. Print your Information
2. Choose to Release or Obtain your records
3. Choose what information to share
4. Read and Sign
Health and Wellness Center · Building 19, Room 177· Phone (413) 755-4230 · Fax (413) 755-6045
Authorization To Release or Obtain Health Records
This form is available online at: www.stcc.edu/healthservices
Please allow two business days from the date of receipt for processing.
1. Print your Information
Name:
STCC ID#:
Date of Birth:
2. Choose to Release or Obtain your records
I hereby authorize Springfield Technical Community College (STCC) to release health information to:
Name:
Phone:
Fax:
I hereby authorize Springfield Technical Community College (STCC) to obtain health information from:
Name:
Phone:
Fax:
3. Choose what information to share
Please select the information to be obtained or disclosed (check all that apply):
Records of immunity and tuberculosis screening
Physical Exam Records
Medical Evaluation Records
Drug Screening Results
Professional licenses and certifications
Permission to discuss/share patient health information
4. Read and Sign
This authorization will be in effect for the duration of your enrollment at STCC. You have the right to revoke
this authorization, or limit the information released, at any time.
If you have any questions regarding this release of information, please contact the Health and Wellness Center at
(413) 755-4230. The signed and dated form must be returned to the Health and Wellness Center.
I have read the above statements and am aware and agree to the sharing of my information with/from the
individual/organization named above.
(signature)
(date)
Updated 1/7/2020 mc
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Authorization To Release or Obtain Health Records (Springfield Technical Community College)

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Completed 26 July 2020

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