Health Services Release of Information

In compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Family Educational Rights and Privacy Act (FERPA), the Aurora University Wellness Center requires your written consent before disclosing any personal health information. Your consent to share this information may be withdrawn in writing at any time, so long as such documents are specific as to information covered, dated, and signed.
Client Information
Name:

First NameLast Name
AU email:
example@example.com
Date of birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Student ID number:
Last semester attended:
I, First Name* Last Name*, authorize AU Wellness Center staff to release and/or obtain information.
Release information?
Release information to:

Other
Release the following information:

Other
Date of delivered care:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Release for the purpose of:

Other
Obtain information?
Obtain information from:

Other
Obtain the following information:

Other
Date of delivered care:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Obtain for the purpose of:

Other
Rights and Responsibilities
This consent will automatically expire one (1) year after the date of my signature as it appears below.

I am aware that I have the right to refuse to sign this form and that I may revoke this consent at any time by giving written notice. I understand once information is released it becomes the property of the recipient. The information released may only be used for the purpose(s) written above.

By signing, I recognize that Aurora University is no longer responsible for the safety and handling of release records.
I agree to these rights and responsibilities:
Signature Value
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Please verify that you are human:
Should be Empty:

Client Information

Rights and Responsibilities