Directions For Completing Medical Requirement Forms Page 7
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8Consent to Disclosure of Personal Health Information
I _____________________________________, (name) hereby give permission to
______________________________________, (name of health provider) of
______________________________________ (agency name) to disclose medical information to the
Anishinabek Educational Institute’s RPN Program. Listed below is the information I agree to have
disclosed:
1. Immunization History
2. Other – Specify:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
This notice shall serve as sufficient authorization and direction to make this disclosure.
Should I choose to revoke my consent, I will inform the above-named agency and the Anishinabek
Educational Institute in writing.
Student’s Signature __________________________________ Date: ____________________________
Witnesses Signature: ________________________________ Name: ____________________________
Medical Form
Page 7
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