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Form 104 - Ohio Northern University Hipaa Compliant Authorization For The Release Of Protected Health Information

FORM 104

Ohio Northern University

HIPAA Compliant Authorization

for the Release of Protected Health Information

The Individual who is the subject of the information:

________________________________________________________________

Name

Address

does hereby AUTHORIZE THE DISCLOSURE of specified health information as

follows:

__________________________________________________________________

Name of Provider

__________________________________________________________________

Address of Provider

__________________________________________________________________

Phone and fax numbers of Provider

is hereby authorized to release to:

__________________________________________________________________

Disability Services Representative

__________________________________________________________________

College of Enrollment

Ohio Northern University

525 South Main Street

Ada, OH 45810

Phone: ____________________________________________________________

Fax: ______________________________________________________________

E-mail:____________________________________________________________

the following health information:

Information described on the attached Form 102.

05/08

Form 104 - Ohio Northern University Hipaa Compliant Authorization For The Release Of Protected Health Information