Fillable STATE UNIVERSITY OF NEW YORK AT FREDONIA CONSENT (State University of New York at Fredonia)

Fill Online, Printable, Fillable, Blank STATE UNIVERSITY OF NEW YORK AT FREDONIA CONSENT (State University of New York at Fredonia) Form

Use Fill to complete blank online STATE UNIVERSITY OF NEW YORK AT FREDONIA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

STATE UNIVERSITY OF NEW YORK AT FREDONIA CONSENT (State University of New York at Fredonia)

On average this form takes 4 minutes to complete

The STATE UNIVERSITY OF NEW YORK AT FREDONIA CONSENT (State University of New York at Fredonia) form is 1 page long and contains:

  • 2 signatures
  • 0 check-boxes
  • 6 other fields

Country of origin: US
File type: PDF

U.S.A. forms for State University of New York at Fredonia

BROWSE STATE UNIVERSITY OF NEW YORK AT FREDONIA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
STATE UNIVERSITY OF NEW YORK AT FREDONIA
CONSENT TO RELEASE & RECEIVE CONFIDENTIAL INFORMATION
Fredonia ID #
I,
,
(DOB), hereby authorize
that information regarding myself, which may include personal, psychological, psychiatric and
medical records and opinions, be both released and received by:
Name:
Address:
_ Residence Life
_State University of New York at Fredonia
and
The Counseling Center
State University of New York at Fredonia
Fredonia, New York 14063
T: (716) 673-3424
F: (716) 673-3140
The specific information to be exchanged is as follows:
_Attendance in counseling
_
Recommend ation s
The purpose of releasing this information is for: Coordination of Services
I understand that I may revoke this consent at any time except to the extent that action based on
this consent has been taken. This consent will expire automatically after 365 days from the date
on which it is signed or for the duration of counseling services.
In consideration of this consent, I hereby release the above parties from any and all liability
arising therefrom. A photocopy of this release is to be considered as valid as the original.
(Signature of client or guardian) (Date)
(Signature of witness) (Date)
Client name (printed):
Updated 08/20
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

STATE UNIVERSITY OF NEW YORK AT FREDONIA CONSENT (State University of New York at Fredonia)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 1 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document