Consent For Release Of Medical Information From Emory University Student Health Services
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1Emory University Student Health Services
1525 Clifton Road, Atlanta, Georgia 30322
Phone 404.727.7551
Fax 404.727.5349
Consent for Release of Medical Information
from Emory University Student Health Services
Name of Patient: _____________________________________ Student ID #: __________________ Date of Birth: ____________
Emory University, through its Emory University Student Health Services, is authorized to release to:
__________________________________________________________________________________________________________
(Name of Agency or Individual to Whom Release of Information is Authorized)
the following information or documents:
Release by means of: Fax: Fax # (_____) ______-_______ Mail: ____________________________________________
Street Address
Release records directly to me (hand carry)
____________________________________________
State
City
Zip
If checked below, I also request Emory University Student Health Services to specifically release the following records to the
above agency or individual and waive any privilege with respect to these specific records:
Records regarding the evaluation and/or treatment of mental health
Records of infectious or contagious diseases (including HIV/AIDS confidential information)
Records of drug or alcohol abuse or treatment of same
I hereby release Emory University Student Health Services, its officers, partners, agents and employees from any and all liabilities,
responsibilities, damages and claims that may arise from the release of information authorized above. I understand that once this
information has been disclosed to a party other than a health care provider or health plan covered by the federal privacy regulations,
the information may be re-disclosed and is no longer protected by the federal privacy regulations.
I acknowledge that this consent is valid until __________________________, 20____________. If I fail to specify an expiration
date, this consent will be valid for 90 days from the date of my signature.
I understand that I may refuse to sign this consent, and that such refusal will in no way affect my ability to receive treatment,
payment for treatment or my eligibility to receive health plan benefits. I understand that I can withdraw this consent for release of
information at any time prior to this expiration date, except to the extent that action has been taken in reliance hereon. I further
understand that Emory University Student Health Services may refuse to release records where it will be detrimental to my physical
or mental health.
Should I wish to revoke my consent for the release of information, or if I disagree with a refusal to release
records, I should do so in writing as set forth in the Emory University Notice of Privacy Practices (Effective Date: April 14, 2003).
__________________________________________
_________________________________________________________
Date
Signature of Patient
__________________________________________
_________________________________________________________
Representative’s Relationship to Patient*
Legal Representative*
* Special circumstances, which necessitate other than Patient’s signature (for example, patient is less than 18 years of age)
Office Use Only
Completed by: _________________ Faxed to ___-____-______ Mailed Released to Patient Date: __________
Staff Members Name
Revised May 2007
Form B
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