Authorization Form For Release Of Medical Information printable pdf download

Illinois Institute of Technology Student Health & Wellness Center

IIT Tower, Suite 3D9-1

10 W 35th St, Chicago, IL 60616

Phone: 312.567.7550 Fax: 312.567.5702 Email:

student.health@iit.edu

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

STUDENT/PATIENT INFORMATION

(Please include a picture ID with your

request):

Name: _______________________________________

DOB(mm/dd/year):____ /___ /_____

CWID: _______________________________________

Semester of Entrance: _____/______

Phone: (

) _______________________________

Email:__________________________________

Please Note: There is a charge of $5 to release your requested records. Payment is due at the time request is made.

Payment may

be made online at

I APPROVE THE RELEASE OF MEDICAL RECORDS TO:

Name: ___________________________________________________

Mail Address:__________________________________________

__________________________________________

*Fax: ( _________ ) -______________________________________

Pick Up - You will be called when your records are available for pick up; records will only be held for 1 week.

* We cannot mail or fax internationally

Release the following Information

Mental Health Record

Immunization Records

Health Records

Lab Results

Other:______________________________________

Please Note: All records are processed within 7-14 business days. Due to confidentiality, records are not released via e-mail.

DISCLOSURE INFORMATION

I understand that my records are protected under law and cannot be disclosed without my written permission unless

otherwise provided by statues and regulations. I have the right to revoke this consent by written statement at any time prior

to release. I understand that I have the right to inspect and copy the information to be disclosed although in certain

instances applicable states or regulation may place restrictions on this right. No information shall be disclosed to other

individuals or agencies. This consent expires at the end of every semester unless earlier revoked by me in writing.

Patient Signature: ________________________________ Today’s Date(mm/dd/yyyy):____/____/_______

Witness Signature: _______________________________ Witness Name:_____________________________________

FOR OFFICE USE ONLY

Date Received: __________Payment Received: Yes or N/A Date Completed: __________ Time ______Initials:____ (F) (M) ( P/U)

Authorization Form For Release Of Medical Information