State University of New York at Fredonia
Consent to Release and Receive Confidential Information
I, ________________________________________hereby authorize that information regarding myself, including
personal, psychological, psychiatric, and medical records and opinions be both released and received by:
Office of Student Conduct
State University of New York at Fredonia
Fredonia, New York 14063
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 requested is as follows: counseling attendance, completion of evaluation,
recommendations, and progress towards wellness. 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): ____________________________________________________
This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit
you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the
person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other
information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any
alcohol or drug abuse patient.
The above student:
□ Has completed the evaluation; no additional recommendations.
□ Has completed the evaluation and has recommendations to be completed by _______________
________________________________________________________________
________________________________________________________________
□
_____________________________________________________________________________
_________________________________________________ ______________________
Signature of provider Date
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
