Ferpa Release Form 2015-16 - Uconn Health - University Of Connecticut printable pdf download

FERPA RELEASE FORM 2015-16

Please return form to:

Registrar’s Office, Room AM039

Email:

REGISTRAR@UCHC.EDU

Fax: 860-679-1902

School of: ☐ Dental Medicine

☐ School of Medicine

Graduating Class of: 20____

Name of Student (Last, First, M.I.)____________________________________________________________

I, the undersigned, hereby authorize the University of Connecticut to release the following educational records

and information (Check the appropriate types of records):

□

BURSAR

 The student’s fee bill balance, charges, debits, credits, and payment appearing on their account. Past due

amounts and/or collection activity, payment plans, third party sponsorship and the 1098-T information.

 Tuition and fee waivers, scholarship or sponsorship awards, refund or excess amounts, and their processing

status.

 University-maintained loan disbursements, loan billing and repayment history (including eligibility).

□

FINANCIAL AID

 The student’s pending, current or previous financial aid awards (including types and amounts), certain financial

aid application data, document requests, processing status, eligibility, or disbursements.

□

REGISTRAR



Enrollment status, grades

□

STUDENT HEALTH PLAN

 Health insurance waiver status.



Please be advised that no detail regarding the nature of Health Services received will be disclosed

The records checked above may be released to (indicate maximum of 4 names): _______________________

________________________________________________________________________________________

for the purpose of: _________________________________________________________________________

for the duration: (

)______________

duration will be to the end of the current academic year, unless otherwise indicated

For identification purposes I have assigned them the following 4 character Access Code: ________________

I understand further that: (1) I have the right not to consent to the release of my education records; (2) I have

the right to revoke this consent at any time.

This information is released subject to the confidentiality provisions of appropriate state and federal laws and regulations

which prohibit any further disclosure of this information without the written consent of the person to whom it pertains, or as

otherwise permitted by such regulations

Student’s Signature: ___________________________________ Date: ______________________

For Office use:

Distribution List – Bursar, Financial Aid, Registrar, Health

Submitted to (indicate office): ______________________

Plan

Ferpa Release Form 2015-16 - Uconn Health - University Of Connecticut

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