Authorization Form For Release Of Information
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1A.H. Ray Student Health Center, Room 244
Student Health Services
Phone (336) 750-3301
601 S. M.L. King Jr. Dr.
Fax (336) 750-3303
Winston-Salem, NC 27110
AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby authorize the Winston-Salem State University’s Student Health Services to release medical information to:
TO: _________________________________________________________________
METHOD OF RELEASE:
(Name of facility where information is to be sent/ or Your name if information is to be given to you)
(CHECK ONE)
ATTN
: _____________________________________________________________________
______ Mail to address given
______ Fax to number given
______ Released to Student
PHONE: (____)________________
FAX: (____)_______________
ADDRESS: __________________________________________________
__________________________________________________
__________________________________________________
STUDENT STATUS:
(CHECK ONE)
RE:
_________________________________ D.O.B ___/___/___
______ Current Student
(Student’s Name)
______ Returning Student
______ Transferring to
PHONE NUMBER: ____________________________________________
another school
(Student’s Number)
MAIDEN NAME: ______________________________________________
(If Applicable)
GRADUATION DATE: _________________________________________
(If Applicable)
REQUESTED INFORMATION:
_____________________________________________________________________________________________________
*Please provide date(s) of treatment below for medical information that you are requesting, except immunization records.
Date(s) of treatment: _____________________________________________
STUDENT’S SIGNATURE: ______________________________________ DATE: ______________
WITNESS: ___________________________________________________
DATE: ______________
Completed by: ________________________________________________________ Date/time:____________________
Confidentiality Note
The information contained in this facsimile is legally privileged and confidential information intended only for the use of the individual or entity
named above. If you are not the intended recipient or the employee or agent responsible for delivering this communication to the intended
recipient, you are hereby notified that any reading, distribution or copying of this communication is strictly prohibited. If you have received
this facsimile in error, please notify us immediately by telephone at (336-750-3301)
Winston-Salem State University is a Constituent Institution of the University of North Carolina an Equal Opportunity Employer
REVISED 06/2013
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Parent category: Legal