Consent Form For Release Of Medical Records And Information printable pdf download

Student Health and Wellness Center

1 East 31

Street, N200

Patient label

Baltimore, MD 21218

Tel: 410-516-8270 Fax: 410-516-4784

CONSENT FORM FOR RELEASE OF MEDICAL RECORDS AND INFORMATION

Student Full Name_________________________________________________________________________

Student Date of Birth _____/____/_______ Phone Number _______________________________________

Last Year Attended: ______________

Consent:

By signing this form, I consent to the following:

#1) Johns Hopkins University (JHU) may disclose the medical records and information I specify below from the JHU Student

Health and Wellness Center to the individual or entity specified in #2, upon request:

Please check the appropriate box(es):

☐ All of my medical records and information*^, EXCEPT medical records and information regarding:

☐ Mental health

☐ Reproductive health, including information about contraception

☐ Sexually transmitted infections, including HIV and AIDS

☐ Drug and alcohol use

☐ Other (please specify) _______________________________________________________________

☐ All of my medical records and information*^

☐ ONLY Immunization information

AND/OR

□ ONLY Information about my appointments and whether I have been to or am in the Student Health and Wellness Center

AND/OR

☐ Other (please specify) ______________________________________________________________________

#2) The medical records and information specified in #1 may be disclosed to:

Name (individual, entity or JHU office) _______________________________________________________________

Address ________________________________________________________________________________________

Email Address _______________________________ Phone Number ______________________________________

Fax Number ______________________________________

#3) The above disclosures may be made for the purposes of (check appropriate box(es)):

☐ Keeping my parents informed of my medical and health care and treatment and health status

☐ Giving another health care provider information about my health history so they can provide care or treatment to me

☐ Other ________________________________________________________________________________________

#4) I understand that:



This consent expires one year from the date on which I sign it, unless I revoke it earlier in writing.



I can revoke this consent at any time upon the JHU Student Health and Wellness Center’s receipt of my signed, dated

revocation. The revocation does not affect disclosures that were made prior to JHU’s receipt of the revocation.



Signing this consent is voluntary.



I cannot be denied any educational or health services from JHU if I do not sign this consent.

Student Signature: ________________________________________________

Date: _______________________

* “All my medical records and information” applies only to medical records and information developed and maintained by the JHU Student Health and

Wellness Center. If you would like to authorize JHU to disclose medical records pertaining to you that the JHU Student Health and Wellness Center

has received from another health care provider, please check the box marked “Other” and specify the records.

^ Note that this does not include psychotherapy notes created by the JHU Counseling Center. A separate consent is required to release psychotherapy

notes from the JHU Counseling Center. However, my medical records may include some mental health information related to any visits to or treatment

I may receive from the Counseling Center (i.e. diagnosis, medications, etc.).

Revised 02/2016

Consent Form For Release Of Medical Records And Information

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