Authorization to Share Medical Information – Student Development

Authorization to Share Medical Information Form

Student Name

First Last

Date of Birth

Student ID #

Authorization

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.

Provider's Name

Provider's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Provider's Telephone Number

Provider's Fax Number

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.

Specific Purpose for this Disclosure

This authorization for release of information is provided in connection with my application for reinstatement to Kalamazoo College. I authorize Kalamazoo College to use and disclose this information for any and all purposes associated with my application for reinstatement to the College.

Acknowledgements

I acknowledge and understand the following (check each box to confirm):

I am not required to submit this form to receive health care treatment.

I may see and copy the information described on this form if I ask for it.

I may revoke this authorization at any time by sending a written request to the provider listed above, except to the extent that the provider has already taken action in reliance on this authorization.

My electronic signature on this form is as valid as a hand-written signature.

Signature

Type your full name. This will serve as your electronic signature.

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