Authorization To Release Patient-Related Information Including Medical Records
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1AUTHORIZATION TO RELEASE PATIENT-RELATED
INFORMATION INCLUDING MEDICAL RECORDS
Patient Name: _____________________________________
ID#: ________________________________
Maiden or Previous Name(s):__________________________
Date of Birth: ___________________________ __
Last Year of Attendance at Wheaton College:
____________ Phone number: _____________________________
I.
Authorization for Release of Information
I, the undersigned, authorize _______________________________________________________________
Fax/Phone/Address____________________________________________________ and its employees and agents to release
and disclose all information about me that they possess (except for the release of information concerning substance abuse,
mental health, or HIV/AIDS, unless I have specifically authorized the release of such information in Section II below) to the
Recipient(s) identified in Section III below. I understand that unless I state otherwise in this authorization, the information
release may include insurance claim or explanation of benefits, intake questionnaires, immunization records, health history
records, physical examination records, consultation reports, diagnostic reports, operative reports, laboratory test reports,
photographs, videotapes, X-rays, digital or other images, discharge summaries, treatments, prescriptions, and notes of health
care professionals. I also authorize the release of information received, obtained, or created after the date on which this
Authorization is signed as long as such information is released during the effective period of this Authorization and pursuant to
a legitimate request for such information.
II.
Specific Authorization for Release of Protected Information
(To release this information, you must sign here and at the end of this
form.)
I specifically authorize the release of information related to the following:
□
acquired immunodeficiency syndrome (AIDS) or the human immunodeficiency virus (HIV)
(including but not limited to test results)
□
substance abuse (drugs(s) or alcohol)
□
mental health, behavior, or psychological/psychiatric care or conditions
□
genetic testing/records
_____________________________________________
______________________________
_______________
Patient’s Signature or Patient’s Authorized Representative
Patient’s Printed Name
Date
(Include representative’s name and a description of the representative’s authority: ________________________________________)
____________________________________
__________________________ ____
Witness’ Signature
Printed Name
Date
III. Scope of Disclosure and Duration of Authorization
The information released is to be disclosed to the following persons or entities identified by name or title (the
“Recipient(s)”): Wheaton College – Student Health Services, 501 College Avenue, Wheaton, IL 60187; Fax 630/752-5575;
Phone 630/752-5072.
This listed information to be released is: _________________________________________________________. It includes
the information identified above regarding all consultations/treatments, except: _____________________________________
(specify exceptions, if any).
I understand that I have the right to inspect the disclosed information at any time and request a list of entities to whom
Wheaton College Student Health Services has released my medical records.
I understand that I may revoke this Authorization at any time (except to the extent that action has already been taken in
reliance on it) by delivering to the person(s) or entity authorized to disclose information under this Authorization a signed and
th
written revocation. Unless otherwise revoked, this Authorization will expire on ___________(or on the 365
day from the date
of signing if no date is specified).
A photocopy, facsimile, or exact reproduction of this signed Authorization shall have the same force and effect as the
original.
Provision of treatment is not conditioned upon my execution of this Authorization or the Specific Authorization for
Release of Protected Information contained in Section II of this Authorization.
I have read and fully understand the provisions of this Authorization.
_________________________________
______________________________
________________
Patient’s Printed Name
Patient’s
Signature
Date
_________________________________
______________________________
________________
Authorized Representative’s Signature
Authorized Representative’s Printed Name
Date
(Include description of authorized representative’s authority: ______________________________________)
11/2014
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Parent category: Medical