Authorization For Use, Disclosure, And Release Of Health Information

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University of North Florida, Student Medical Services
Authorization for Use, Disclosure, and Release of Health Information
_______________________________________
_________________
__________________
Patient Name: Last
First
MI
Date of Birth
Student ID Number
I hereby authorize:
To Release Information to:
(Name and address of releasing facility)
(Individual name, facility/organization and address)
________________________________________
____________________________________
________________________________________
____________________________________
________________________________________
____________________________________
PURPOSE OF DISCLOSURE:
All information regarding Alcohol and/or Drug Abuse or
Behavioral Health will be released unless you restrict by
( ) Continuing Care
initialing below:
( ) Payment of Claim
Initial
( ) School
______ do not release Alcohol and/or Drug Abuse information.
( ) Worker’s Compensation
( ) Legal
______ do not release Behavioral Health Information
( ) For Personal Use
( ) Other (specify):
______________________________________________________________________________________
INFORMATION TO BE RELEASED:
Between Dates of: _______________ to _________________
( ) Progress Notes/Provider Notes
( ) Immunization Records
( ) Lab Reports/Results
( ) Diagnostic Test Reports
( ) Consultation Notes
( ) Allergy Records
( ) Prescriptions
( ) HIV related information
( ) STD information
( ) PAP Reports
( ) Depo-Provera Records
( ) GYN Records
( ) Entire Record (excluding special permission records if initialed in above box).
ACKNOWLEDGEMENT OF UNDERSTANDING:
I understand the expiration date of this authorization is _______ or 1 year from today’s date, whichever is sooner.
I understand that I may revoke this authorization at any time by notifying the providing organization in writing, and it will
be effective on the date notified except to the extent action has already been taken in reliance on it.
I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the
recipient and no longer be protected by Federal privacy regulations.
I understand this consent for release of alcohol and/or drug abuse information is subject to revocation at anytime except to
the extent that the program or person, which is to make the disclosure, has already acted in reliance on it.
I understand that SMS may not condition my treatment, payment, enrollment or eligibility for benefits on my signing this
authorization.
I understand that a photocopy or fax of this form is the same as the original.
If I am signing as Authorized Representative of the patient, I am:
( ) Parent of minor
( ) Court appointed guarding/conservator
______________________________________________________
______________________
Patient Signature
Date
___________________________________________
__________________
Signature of Authorized Person
Relationship to Patient
___________________________________________
__________________
Witness
Date
1 UNF Drive Jacksonville, Florida 32224
Phone: (904) 620-2900
Fax: (904) 620-2902

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