A photo copy of this authorization shall be considered as effective and valid as the original.
AUTHORIZATION IS VALID FOR 90 DAYS.
PLEASE ALLOW 5 WORKING DAYS FOR COPYING AND PREPARING RECORDS
STUDENT HEALTH SERVICES
LEWIS-CLARK STATE COLLEGE
500 8TH AVENUE
LEWISTON, ID 83501
(208) 792-2211
Request for Release of Medical Records
Patient Name
Date of Birth
Phone number
Release records from:
MD or Group Name or Individual
Mailing Address
City, State, Zip Code
Important: Please enclose a copy of release form with records to student health.
Release records to:
MD or Group Name or Individual
Relationship if other than Health
Care Provider
Spouse Parent Significant Other Interpreter
Friend Other__________________________________________
Mailing Address
City, State, Zip Code
Date Requested
Appointment Date
The information I request to be released is:
All Medical Records
Progress Notes
History & Physical Exam
Consultation
Mutual Exchange of Information
AIDS/HIV Related Data
Medical Excuse / Release
X-Ray Reports
EKG Report
Laboratory Reports
Other: _ ______________________________________________________________________________________
The date(s) of records that I request to be release is:
All Dates Selected Dates: From: _______________________ To:________________________
Disclosure:
“I understand that my records may contain information regarding the diagnosis or treatment of HIV (AIDS virus), other
sexually transmitted infection, drug and/or alcohol abuse, mental illness, or psychiatric treatment. I give my specific
authorization for these records to be released.”
“I understand that LCSC Student Health Services cannot limit or control the subsequent use or dissemination of medical
information by the party to whom I request the information be furnished. This is a free and voluntary act by me. I
understand that my records may be faxed if there is not time to mail them. I hereby release LCSC Student Health Services
and its staff from all legal responsibility that may arise from the release of the medical information hereby authorized.”
THERE IS NO CHARGE WHEN RECORDS ARE SENT TO A PHYSICIAN FOR CONTINUING CARE. A COPYING FEE IS CHARGED
WHEN RECORDS ARE RELEASED TO A PATIENT OR OTHER NON-PHYSICIAN RECIPIENT.
Authorization:
Patient Signature:
Date:
If minor, parent/guardian
signature:
Date:
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signature
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