Authorization For The Release Of Information - California State University (Page 2 of 2) in pdf

Authorization For The Release Of Information - California State University Page 2

CALIFORNIA STATE UNIVERSITY, LONG BEACH

S T U D E N T H E A L T H S E R V I C E S

Accredited by the Accreditation Association for Ambulatory Health Care, Inc.

FAX: (562) 985-1644

1250 Bellflower Boulevard Long Beach, California 90840-0201 (562) 985-4771

PLEASE READ YOUR RIGHTS BELOW:

1. The recipient of the protected health information is prohibited from

re-disclosing the information unless the recipient obtains another authorization

from me or unless the disclosure is specifically required or permitted by law.

2. Signing this Authorization is not required as a condition to obtaining treatment

at Student Health Services.

3. A copy of this Authorization will be provided by Student Health Services upon

request.

4. Revocation of this Authorization at any time by mailing or personally

delivering a signed, written notice of revocation to the Medical Records Dept.

of Student Health Services. Such revocation will be effective upon receipt,

except to the extent that the recipient has taken action in reliance on this

Authorization.

This Release is executed in conformity with Cal. Civ. Codes Section 56.11 Et Seq.

Authorization for the Release of Information

Medical Records Form #04

revised: 2-6-15

Authorization For The Release Of Information - California State University Page 2