College Health Service
Authorization for Disclosure
1. I, ___________________________________________ , hereby authorize Hudson Valley Community
please print your name
College to release the following (check all that apply):
Immunization Records
Physical Exam Record
Treatment Records, including laboratory information
Other Information (please list) ___________________________________________________
concerning the following condition and/or related date of service:
________________________________________________________________________________
2. Name, address and fax number of person or organization to whom this information is to be released:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
3. Purpose of Disclosure: _______________________________________________________________
4. I understand this is consent for a one time disclosure only
and that the requested information will be
released within five (5) working days of the request. I further understand that I may revoke this consent
anytime before the disclosure has occurred.
I waive any and all claims against Hudson Valley Community College and the College Health Service
in connection with the communication and disclosure of such information as requested.
5. Signed at Hudson Valley Community College this _______ day of ___________________ 20 ________
Signature ________________________________________________________________________
HVCC ID or DOB ___________________________________________________________________
Address __________________________________________________________________________
FOR OFFICE USE ONLY
Witness: _________________________________________________ Date: _________________________
Released by:_____________________________ Date: ___________ Form: letter fax e-mail other_______
Please return this form to:
Hudson Valley Community College
College Health Service
80 Vandenburgh Avenue
Troy, NY 12180
CHS006-12
