3. Your Rights and Responsibilities
Please review and then sign to authorize the disclosure of the information as indicated above:
I understand that I may revoke this authorization at any time. Any such revocation will be valid, except for the release of information that occurred prior to this authorization being revoked. I may inspect and/or copy the information sought to be used or disclosed in this authorization as permitted by applicable law the federal privacy regulations. I understand that by signing this form, I am confirming my authorization that the above mentioned Wheaton College office(s) and its agents may use and/or disclose my educational and treatment records (check those that apply) and information described in this form to the person(s) and/or agency(s) named in this form. I understand that I may request a copy of this authorization after signing below. This authorization is voluntary and I am under no obligation to sign this form and no organization/department may condition treatment, payment, enrollment, or eligibility for benefits on signing this form. I understand that refusing to sign this form does not stop disclosure of information that is otherwise permitted by law without my specific authorization, consent or permission. I understand that in order to revoke this authorization form, a written request must be sent to the Wheaton College office where this authorization form was signed. I understand that revocation of this authorization will not affect any disclosures or actions taken by Wheaton College before receiving the written notice of revocation. I understand that this form is an occurrence-based form and is used only for medical and mental health records if I am a current patient in Student Health Services or a client in the Wheaton College Counseling Center, respectively. The form is available for use by all students who are in communication with a Wheaton College office or employee where a release of information is needed.
I understand that this authorization may be withdrawn by me at any time and that I may modify this authorization through submission of a new Authorization for Release of Information Form. This form is valid for 12 months from date of signing.