Authorization For The Release Of Information - California State University

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CALIFORNIA STATE UNIVERSITY, LONG BEACH
S T U D E N T H E A L T H S E R V I C E S
Accredited by the Accreditation Association for Ambulatory Health Care, Inc.
FAX: (562) 985-1644
1250 Bellflower Boulevard Long Beach, California 90840-0201 (562) 985-4771
A U T H O R I Z A T I O N F O R T H E R E L E A S E O F I N F O R M A T I O N
Patient Name:______________________________ Campus ID#:_______________
First
Middle
Last
Patient Address:_______________________________________________________
City:__________________________________ State:_______ Zip:________
Current Telephone: (____)______-________ Date of Birth: ____/____/_______
I, hereby, authorize the California State University, Long Beach Student Health
RELEASE
Service to
the following information from my medical record:
___Complete Medical Record
___Other:_____________________________
THE PURPOSE OR NEED FOR THE RELEASE
___Personal Records
___Other, describe_____________________________________________________
I release the CSULB Student Health Service from any liability or legal responsibility
that may arise from this authorization. This release is valid FOR THIS REQUEST
ONLY. This authorization shall become effective immediately and shall remain in
effect until records are processed.
Self
I AUTHORIZE THE RELEASE OF MY MEDICAL INFORMATION TO:
Name________________________________________________________________
Address______________________________________________________________
City:______________________________________ State:________ Zip:_________
Phone:_______________________
Fax (if applicable): _____________________
Allow 7-10 days for processing
Records to be:  picked up
 mailed
 faxed
Student Signature
Date
Parent or Guardian Signature
Date
(required if under 18)
For Office/Records Use Only
Date Released:____/____/______
Released By:_________
:
Date left at Front Office for pick up: ______________ Date faxed/mailed: _____________
Authorization for the Release of Information
Medical Records Form #04
revised: 2-6-15

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