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Form 104 - Ohio Northern University Hipaa Compliant Authorization For The Release Of Protected Health Information Page 2

for the following purpose:

Evaluation of my request for accommodations.

I understand that my express consent may be required for the release of information

relating to sexually transmitted diseases, AIDS, mental illness, psychiatric treatment,

and/or drug or alcohol abuse treatment. If I have been tested, treated, or diagnosed in

connection with any such injury, disease, or illness, Provider is specifically authorized to

release those health records (including psychotherapy notes) relating to such diagnosis,

testing, or treatment, as directed in this Authorization. I understand that some of this

health information may be protected under the federal regulations governing the

Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part2, and cannot

be disclosed without my written consent.

This Authorization is a free and voluntary act by me. I understand that, if the Provider is

rendering services to me solely for the purpose of disclosing the health information

generated thereby to the person designated in this Authorization, my failure to provide

this Authorization may result in a denial of service by the Provider. Otherwise, I

understand that my Provider cannot condition my treatment on my signature on this

Authorization.

This Authorization will be valid for one year or until I revoke this Authorization,

whichever occurs first. I know that I may revoke this Authorization at any time, except to

the extent that the Provider may have taken action in reliance thereon, by notifying the

Provider in writing at the address given above. I also understand that the Provider cannot

limit or control the subsequent use, reproduction, or dissemination of the health

information I have authorized to be released. A copy of this Authorization is as valid as

the original.

Individual’s Signature:_______________________________________________

Date:__________________________

Print name:_______________________________________________________

If applicable:

Personal Representative Signature: ___________________________________

Date:__________________________

Print name:_______________________________________________________

Description of Personal Representative’s authority to act for the Individual:

________________________________________________________________

05/08

Form 104 - Ohio Northern University Hipaa Compliant Authorization For The Release Of Protected Health Information Page 2