Tennessee Tech University
Name:__________________________________________
Tnumber:_____________________________________________
DOB:____________________________________________
Phone:___________________________________________
SENDING OR DISCLOSING HEALTH INFORMATION BY TTU: Student Health Services
I authorize the Student Health Services at Tennessee Tech University, Cookeville, TN, to use or disclose the above
named
individual’s health information as described below: The following information is to be disclosed:
Lab results. Please list test (s)/date (s) _________________________________________________
X-ray and imaging reports. Please list test (s)/date (s)_____________________________________
Last visit. Please state date of service__________________________________________________
Other (Please specify date (s) of service or specific information_____________________________
_____________________________________________________________________________________
I understand that the information in my health record may include information relating to sexually transmitted disease,
acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information
about behavioral or mental health services and treatment for alcohol or drug abuse. I do NOT authorize Student Health
Services to disclose any of the following information:
Alcohol/Drug Abuse Sexually Transmitted Diseases Behavioral/Mental Health
This information may be disclosed to and used by the following individual or organization:
Name/Organization____________________________________________________________________________
Address:_____________________________________________________________________________________
City:____________________________ State:_______________ Zip code:____________________
Purpose of disclosure: At the request of the individual
Other___________________________________
I will pick up the copies myself (please allow 24 hours to process and please bring picture ID to pick up). Please mail
the copies to the address listed
above.
THIS AUTHORIZATION DOES NOT EXTEND TO RECORDS MAINTAINED BY TTU’S GUIDANCE AND
I understand that treatment, payment, enrollment in a health plan, or eligibility for benefits is NOT dependent on my
signing this Authorization. However, TTU Health Services may deem the provision of health care for the purpose of
disclosing to a third party protected health information specifically created for that third party, or for participating in
research related treatment, upon my agreement to use and disclose this
information.
By signing below, I acknowledge that I have read and understand this document, that I have voluntarily given my
authorization to the Student Health Services to disclose my records, and that I may revoke this Authorization at any time
by providing a written notice to the Student Health Services to the attention of Medical Records. The revocation shall
be effective except to the extent that SHS has already used or disclosed information from the Authorization.
I understand that my information may be re-disclosed by the Authorized person/organization receiving the information,
and at that point, the information may no longer be protected under the terms of this agreement.
Click in the spaces below to complete this form on-line, (use the Tab key to move to next blank). Print to sign
