Consent and Release
Permission is hereby voluntarily granted to the Director of Student Health Services, the College Physician(s), nurses, counselors and employees of the Julia Church Health Center to do all such things as may be necessary to diagnose, treat and care for the needs of the named student. I am aware that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantees have been made to me as the result of the treatment or examination in the Julia Church Health Center.
I certify that I understand the contents of this consent form, and that my signature represents a free voluntary act of consent there to on behalf of the student. I further certify that I expect any specific information regarding any service from the Julia Church Health Center will not be released without the express written consent of the student unless disclosure is mandated by law or in the professional judgment of the Director of Health Services or the College Physician(s) is necessary to protect the physical safety of the student or the community at large.
I hereby authorize any health care facility or health care provider to furnish to the Director of Student Health Services or the College Physician(s) medical records and information pertaining to the medical history, mental or physical condition, services rendered, or treatment of the patient named below. This authorization shall remain in effect until revoked in writing. A photocopy of this authorization shall be deemed as valid as the original.
In case of illness or accident deemed serious by the Director of Student Health Services or the College Physician(s), I authorize said persons to notify the parent or guardian named on my medical history form, and the Dean of Students Office if I am unable to do so. I hereby authorize the College Physician(s), College Counselor or Director of Student Health Services to refer me to the appropriate facility for evaluation in case of medical or mental health emergency.
Student athletes: The Julia Church Health Center and the Hiram College Athletics work in conjunction to achieve the best patient outcomes for our student athletes. I hereby authorize release of medical information that is relevant to my participation in athletics to the Hiram College athletic trainers, coaching and/or administrative staff, Hiram College team physician and/or associates.
The Privacy Act Practices Document has been provided for me, I am aware it can be found at http://www.hiram.edu/images/pdfs/health-services/privacy-act-practices.pdf . I have read the document and understand my privacy rights as a patient in the Hiram College Julia Church Health Center.