Tennessee Tech University Name:__________________________________________
Student Health Services SSN:___________________________________________
P O Box 5096 DOB:__________________________________________
Cookeville, TN 38505 Phone:_________________________________________
Phone (931) 372-3320
Fax (931) 372-3848
Receiving Medical Records at TTU Health Services
TO: _____________________________________
_____________________________________
_____________________________________
I, ________________________________, hereby authorize the release of the following information to the
Student Health, Tennessee Tech University, Cookeville, TN. Fax number (931) 372-3848. Please send the records to
the attention of__________________________________________________________________________________.
_____Initial evaluation _____Entire medical record
_____Progress Notes _____History and Physical
_____Consultation Reports _____Psychological testing
_____Discharge/treatment summary _____Immunization Records
_____TB skin test _____Women’s Health notes
_____Allergy shot information _____Laboratory/Cytology reports
I further authorize you to discuss the above noted information with _____________________________ at
the Student Health Services.
I understand that my information may be re-disclosed by the authorized person/organization receiving the
information, and at that point, the information may be no longer be protected under the terms of this agreement.
I understand that treatment, payment, enrollment, or eligibility in a health plan, or eligibility for benefits is NOT
dependent on my signing this Authorization.
I understand that by refusing to sign this authorization may result in the doctor declining to provide the health
care, which is for the sole purpose of creating protected health information for disclosure to a third party. Patient
Initials:__________
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 in
writing at any time. This consent form will expire one (1) year following the date signed or upon my request.
Signature__________________________________________________
Date_______________________________
*The above authorization is given on this patient’s behalf because the patient is a minor, or is unable to sign for
the following
reason:_________________________________________________________________________________
__________________________________________________________
Date_________________________________
*Signature of Closest Relative or Legal Guardian (state relationship)
