DOB DOB: _________________________
108 SW Memorial Place Plageman Bldg.
Corvallis, OR 97331
P 541-737-7609 | F 541-737-5528
CONSENT/AUTHORIZATION TO DISCLOSE MEDICAL RECORDS
I hereby consent and authorize the exchange of medical information.
(Instructions on the Back)
Patient Name OSU ID# Date of Birth
Release Records From (Clinician/Facility who has the records now):
Release Records To (whom do you wish to release/exchange records with?) This includes verbal exchange:
Please check how you would like the records to be
released (If going to another facility Fax or mail is
the only route):
___ Encrypted Email ___ Fax
___ Printed/In Person ___ Mail
To release the following information (check all that apply):
Entire Medical Record or only (please specify):
Most recent two years of medical history.
Diagnostic imaging reports
TB information, including x-ray if applicable
Most recent annual exam and pap
If the information to be disclosed contains any of the types of records or information listed below, additional laws relating
to the use and disclosure of the information may apply. I understand and agree that this information will be disclosed
ONLY if I place my INITIALS in the
applicable space next to the type of information.
Genetic testing information
Drug/alcohol diagnosis, treatment, or referral information
Mental health information
What is the purpose for which this information will be used? (Check the purpose of disclosure):
Continuing Care Internship College Entrance Other:
You do not need to sign this authorization. Refusal to sign the authorization will not adversely affect your ability to receive health care services
reimbursement for services. The only circumstance when refusal to sign means you will not receive health care services is if the health care
services are solely for the purpose of providing health information to someone else and the authorization is necessary to make that disclosure.
You may revoke this authorization in writing at any time.
If you revoke your authorization, the information described above may no longer
used or disclosed for the purposes described in this written authorization. To revoke this authorization, please send a written
Medical Records at OSU Student Health Services, 201 Plageman, Corvallis, OR 97331 and state that you are revoking this authorization. If and
to the degree consent is required to release personally identifiable information in these records under the Family Education Rights and Privacy
Act, 20 USC 1232(g), (collectively referred to as FERPA), this signed document signifies such consent.
I understand that the information used or
disclosed pursuant to this authorization may be subject to disclosure and no longer be protected
under federal law. However, I also understand
that federal or state law may restrict disclosure of HIV/AIDS information, mental health information, genetic testing information and drug/alcohol
diagnosis, treatment or referral information. I have read this authorization and I understand it
This authorization is effective immediately and shall remain in effect for one (1) year.
If you would like it to expire sooner please place date here (
not today’s date
Signature of patient or personal representative Today’s Date Your Phone Number
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