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

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

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

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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:
_Student Health Center
Address: _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:
_Medical and mental health records
_
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 8/20
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STATE UNIVERSITY OF NEW YORK AT FREDONIA CONSENT (State University of New York at Fredonia)

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Completed 1 February 2021

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