Authorization For Release Of Medical Information
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1Please Note
Turn Around Time
Boston College
For Medical Records
Is Between
Health Services Rm. 005
7-10 Days
140 Commonwealth Ave. Chestnut Hill, MA 02467
Tel: 617 552-3225
Fax: 617 552-1671
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
Step 1: Information about you:
Date of
:
Name:_
Other names (maiden)_
Birth
Last
First
MI
Address:
BC ID#
Street City State Zip
o
Tel (cell) number:
Fax:
E-mail:
Student Status:
o
o
o
Undergrad
Graduate
Transfer
Evening Year started:
Year Graduated:
(Class Of:)
Step 2: To whom do you wish to release your records to:
Name of Person/Facility, Address, Phone or fax number as applicable
Release the following Information:
o
o
o
Entire Medical Record
Immunizations only
Other:_
Specific Dates: From
to
Step 3: Authorization and Signature
I hereby authorize
to release the records as described above. This
authorization is valid for 90 days and may be revoked in writing at any time, except to the extent that action has
already been taken in response to this authorization. I also release BC health Services from any liability or legal
responsibility in connection with the release of the above information. I do not give permission for any other use or re-
disclosure of this information.
I also accept the risk and consequence of faxing medical records.
Patient Signature
Guardian Signature(if under 18)
Witness
Date
Step 4: Release for Sensitive Information
I understand that if my medical record contains information in reference to drugs and/or alcohol abuse,
psychiatric, venereal disease, social service, Hepatitis B testing/treatment and/or sensitive information, I agree
to the release of this information, with my signature and date on the lines below.
Patient Signature
Date
Step 5: Release of HIV Information
In addition to the above signatures, if you want your HIV (AIDS) testing/treatment records released, I agree to
the release of this information, with my signature and date on the lines below.
Patient Signature
Date
Below is for BC Use Only
Date Received:
Date Sent:_
Initial:
Mailed:
Fax:
Pick up:
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