Authorization Form For Release Of Information - Counseling And Psychological Services
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1University Health Center
Counseling and Psychological Services
AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION
(PLEASE PRINT CLEARLY)
Patient Name (Last, First, M.I.)
Date of Birth
Address
City
Zip Code
State
Phone Number
UNL ID / Other ID Number
I authorize (Provider/Facility Name)
Phone Number
Fax Number
Address
City
Zip Code
State
To release my mental health information to:
University Health Center
Phone: 402-472-7450
Attn: Counseling and Psychological Services
Fax:
402-472-4593
1500 U Street
Lincoln, NE 68588-0618
I authorize the UNIVERSITY HEALTH CENTER to release my mental health information to:
Name (Person/Organization)
Phone Number
Fax Number
Address
City
Zip Code
State
Information to be requested/released
Include information relating to
Date(s) of Service
☐
☐
Intake
HIV testing/infection or AIDS
From: ________________________________
☐
☐
Progress Notes
Psychiatric care/mental health
☐
☐
Assessment Intake/Reports
Treatment for alcohol and/or drug abuse
To:
________________________________
☐
Attendance Dates
Purpose
Method of Disclosure
☐
Closing Summary
☐
☐
☐
☐
Mental Health Care
Fax
Will pick up
Medication List
☐
☐
☐
Insurance
Mail
Date:
Psychiatric Intake
☐
☐
☐
Legal/Attorney
Verbal
_____________________
Substance Abuse Evaluation
☐
☐
Self (fees apply)
Time:
Other _____________________________________
☐
_____________________________________________
Other _______________________________
_____________________
I understand this authorization may be revoked in writing at any time, except to the extent that action has been taken in reliance on this
authorization. Unless otherwise revoked, this authorization will expire 12 months after the date of execution by the patient or their representative.
I may request a copy of this authorization. If I do not sign this form, the University Health Center will not release my information to any person or
organization except those authorized by law. My health care or payment for care will not be affected by my refusal to sign, except where records
are required for treatment. Once disclosed, Federal privacy regulations will no longer apply and the information may be subject to redisclosure. A
photocopy of this authorization is as valid as the original.
Patient Signature ___________________________________________________________________
Date ________________________
UNL Provider Approval _______________________________________________________________ Date ________________________
Representative/Parent Signature _____________________________________________________________________________________
Relationship _______________________________________________________________________
Date _______________________
Nebraska state law allows 30 days for providers to furnish a copy of the medical record after a written request is received.
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University Health Center
University of Nebraska–Lincoln
1500 U Street
Lincoln, NE 68588-0618
402-472-7450
Fax 402-472-4593
health.unl.edu
March 2015
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