Authorization For Release/Request of Information

AUTHORIZATION FOR RELEASE/REQUEST OF INFORMATION
Name of Student (Please Print)
Date of Birth*

MonthDayYear
Student ID #*
I hereby give my permission to Henderson Student Counseling Services or to the entity listed below to release information contained in my medical record. I understand that my medical record may contain information concerning my psychiatric, psychological, drug or alcohol abuse, sexual abuse treatment, HIV/Acquired Immune Deficiency Syndrome (AIDS) and/or related conditions, and that under Florida law these records are classified as privileged and confidential and cannot be released to me or those designated by me or my legal guardian without an expressed and informed consent. In addition, I understand that those records will not be released to entities other than those designated by myself or my personal representative or otherwise provided in Florida or federal law.
This information will be released/requested upon request to the following:
To/From

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name and Address of Person(s), Agencies, Organization to which information is to be released/requested.
Purpose of this release/request:
I authorize release/request of information covering treatment dates:
Yes
From:

MonthDayYear
Date
To:

MonthDayYear
Date
The type of information to be disclosed/requested is as follows:
Treatment PlansProgress ReportsHealth/Medical RecordsEducation ReportsDischarge SummariesPsychological/Psychiatric EvaluationsSocial/Developmental HistoryVerbal CommunicationOther
Treatment PlansProgress ReportsHealth/Medical RecordsEducation ReportsDischarge SummariesPsychological/Psychiatric EvaluationsSocial/Developmental HistoryVerbal CommunicationOther
I understand that I have the right to withdraw my authorization at any time except to the extent that action has already been taken pursuant to the authorization. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to Henderson Student Counseling Services.(Please Initial)
I understand that authorizing the disclosure of this health information is voluntary, I can refuse to sign, and Henderson Student Counseling Services will not base my treatment, payment or eligibility for benefits on whether or not I provide authorization for the requested use or disclosure. I understand that the recipient may be prohibited from disclosing substance abuse information. I understand that I may inspect or copy the information to be disclosed, as provided in CFR164.524 (with reasonable charge).(Please Initial)
I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient of the information and is no longer protected by federal confidentiality laws or Henderson Student Counseling Services. (Please Initial)
I understand that Henderson Student Counseling Services will release only the minimum amount of information necessary to fulfill a request. (Please Initial)
For Release:
Signature*

Clear
Today's Date*

MonthDayYear
Date
For Request:
Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

AUTHORIZATION FOR RELEASE/REQUEST OF INFORMATION