Counseling and Prevention Resource Center
Indian Hills Community College * 525 Grandview Avenue Ottumwa, IA 52501 * 641-683-5152
Authorization for Release of Confidential Information
I, ______________________________________________________________ (student name/ID/DOB), authorize Indian Hills
Community College Counseling and Prevention Resource Center, to disclose to (name/position/title/department)
___________________________________________, located at (address/phone) ___________________________________,
the following Protected Health Information, by written or verbal communication:
Attendance Record Crisis Intervention Note(s) – all or specific: ___________________
Treatment Recommendation(s) Brief Clinical Assessment
Treatment Status Progress Note(s) – all or specific: __________________________
Discharge Summary Other Assessment (specify): ______________________________
Other: _________________________________ Complete Student Client File
For the Purpose of:
Compliance with attendance Coordination of Services
Referral for New Service(s) Other: ___________________________________________
I UNDERSTAND THAT THE INFORMATION RELEASED AND/OR OBTAINED WILL BE USED AS APPROPRIATE AND NECESSARY
FOR MY TREATMENT, AND DOES NOT CONSTITUTE BREACH OF MY RIGHTS TO CONFIDENTIALITY. I ALSO UNDERSTAND
THAT I MAY REVOKE THIS CONSENT AT ANY TIME EXCEPT TO THE EXTENT THAT ACTION HAS BEEN TAKEN IN RELIANCE ON
IT. I UNDERSTAND THAT I HAVE THE RIGHT TO INSPECT THE INFORMATION TO BE DISCLOSED, UPON PROPER
NOTIFICATION TO, AND UNDER APPROPRIATE CONDITIONS ESTABLISHED BY, THE INDIAN HILLS COMMUNITY COLLEGE
COUNSELING AND PREVENTION RESOURCE CENTER. This consent expires automatically at:
End of school year _______________ End of term ______________ Other: ______________
A photocopy, or exact reproduction of this authorization, as duly executed, shall have the same force and effect as the original.
Printed Name of Client/Legal Guardian: __________________________________ Relationship to Client: ________________
Signature of Client/Legal Guardian: ______________________________________ Date: ________________________
Printed Name of Witness: __________________________________ Signature of Witness: ____________________________
SPECIFIC AUTHORIZATION FOR RELEASE OF INFORMATION
PROTECTED BY STATE AND FEDERAL LAW.
I authorize the release of the information listed below,
which requires specific consent under federal law (check appropriate boxes):
1. M
ental Health:
2. S
ubstance Abuse:
3. H
IV Related Information:
_______________________________________________________________
PR
OHIBTION ON RE – DISCLOSURES:
42 CFR Part 2 prohibits unauthorized disclosure of these records.
Copy of Release Given to Client?
Yes No
___________________________________
Client Revoked; Date: _____________
IHCC CPRC Initials: _____________
___________________________________
DELIVERY METHOD: Urgent
Mail Fax Pick Up Phone
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