UAF SHCC Release of Information for UAF Athletics

Student Health and Counseling Center

P.O. Box 755580, 1007 N. Chandalar Drive | Fairbanks, AK 99775-5580 | PH: 907-474-7043, FX: 888-837-2146| www.uaf.edu/chc
UAF STUDENT HEALTH AND COUNSELING CENTER AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION
Date of request*

MonthDayYear
today's date
Student name*

First NameLast Name
Student date of birth*

MonthDayYear
Date
Student UA identification number*
8 digits and starts with a 3
Student address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student telephone number*
xxx-xxx-xxxx
I HEREBY AUTHORIZE THE DISCLOSURE AND USE OF MY HEALTH INFORMATION BETWEEN:
UAF Student Health and Counseling Center (UAF SHCC)

1007 N. Chandalar Drive, PO Box 755580 Fairbanks, AK 99775

Phone: (907)474-7043; (Fax): (888)837-2146
AND
UAF Athletics Department

1890 Tanana Loop Room 209 Fairbanks, Alaska 99775-7440

Phone: (907)474-2435
I HEREBY AUTHORIZE INFORMATION TO BE SHARED:

TO AND FROM, UAF SHCC and UAF Athletics DepartmentFROM UAF SHCC TO UAF Athletics Athletics DepartmentFROM UAF Athletics Department to UAF SHCC
Type of records/information to be released:

Status of Immunizations and test resultsPhysical health information pertinent to training and competitionOther
What is the purpose of this disclosure?*

Compliance with competition and travel requirementsHealth careCoordination of services
Expiration of Authorization: This authorization will expire in one year
Re-disclosure: I understand that when the information is disclosed pursuant to this Authorization to someone who is not required to comply with the federal or state privacy protection requirements, it may be subject to re-disclosure by the recipient and may no longer be protected.

Revocation: I understand that I may revoke this Authorization at any time by writing to the address above. A request to revoke my authorization will not apply to the extent that SHCC has taken action in reliance upon this authorization.

Conditioning of Eligibility: SHCC will not condition treatment, payment, and enrollment or benefit eligibility on my signing this document.

If you are under age 18, your legal parent/guardian must sign this form.
Name of person signing this form*

First NameLast Name
Please indicate the choice below that describes your role in signing this form.*

I am age 18 or older and have legal authority to sign this form on my own behalf.I attest that I am the legal guardian of the student identified on this form and have the authority to consent for their release of health records.
Date of Signature*

MonthDayYear
Date
Signature*

Clear
The UAF Student Health and Counseling Center reserves the right to authenticate the patient's signature/guardian's signature on forms received by fax or mail prior to the release of the requested information.
FOR INTERNAL OFFICE USE ONLY
Records released as instructed by:

First NameLast Name
UAF is an affirmative action/equal opportunity employer, educational institution and provider and prohibits illegal discrimination against any individual: www.alaska.edu/nondiscrimination/.
Should be Empty:

Student Health and Counseling Center