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_____________ ____________________________________________________
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CONSENT FOR RELEASE OF INFORMATION OR RECORDS
I HEREBY AUTHORIZE
(name of person sending the information):
Name
Organization
Address
City State Zip Code
Phone/fax Email
TO BE RELEASED TO
(Name of receiving person, agency, or institution):
Name
Organization
Address
City State Zip Code
Phone/fax Email
Information (including counseling/psychotherapy, medication, psychiatric/psychological assessment, testing,
recommendations, and relevant medical information and lab reports), pertaining to the care and treatment of:
Name:________________________________ Date of Birth: _________ ______ Student No.:
This consent includes the release of any or all records pertaining to:
Initials ( ) Alcohol and/or drug abuse treatment
( ) Mental Health & Psychiatric Care/Assessment
( ) A condition related to a sexually transmitted disease including human immunodeficiency
virus (HIV)
________ I understand such information cannot be released without my specific consent.
Initials
________ Disclosure is authorized for the following report(s)/information only:
Initials ________________________________________________________________________
________ Disclosure of the record(s)/information may be used only for the following purposes:
Initials ________ Continuing Care
________ Other (specify)
I have read this authorization and I understand it. Unless revoked, in writing, this authorization will expire in one year OR
__________________ (specify date). If I fail to specify an expiration date or event this authorization will expire 360 days from the
date it was signed. I understand that consent may be revoked at any time by written request, and that not signing this
authorization will not adversely affect my ability to receive services. I have read and initialed that I understand the information
below regarding “redisclosure”.
Date Signature of Student or Authorized Representative
Signature of Kapi’olani Community College Representative
*****Redisclosure Information-please initial after reading
________ I understand that the information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient of
the information because some information is not protected under federal or state law. However, I also understand that federal or state law
may restrict the redisclosure of HIV/AIDS, mental health, and drug/alcohol diagnosis/treatment/referral information, as specified previously on
this form. Kapi’olani Community College, Ka’au Program will not re-dislcose any information received from another party unless authorized by
the student.
