I authorize the provider listed below to release or disclose health information about me to the Kalamazoo College Student Health Center, the Counseling Center, and/or the Division of Student Development.
Description of Health Information
All pharmacy records; any and all records and documents pertaining to any treatment/consultation rendered or performed, including but not limited to: complete in-patient and outpatient hospital records, surgical records, emergency room records, rehabilitation records, therapy, lab studies, radiographic films and reports, actual office notes, patient files, narrative reports, billings, and medications prescribed and/or filed. This authorization includes alcohol, mental health and substance use records, including psychotherapy notes. This authorization applies to any and all records from [date when LOA started] through the date listed below. It applies only to records that are related, in any way, to the reasons for my leave of absence from Kalamazoo College. This authorization also permits oral communications regarding the listed information between agents of Kalamazoo College and the provider identified above. This authorization expires one year after the date below.