Authorization To Release Obtain Medical Records printable pdf download

Student Health Services

Date Received – Official Use Only

University at Buffalo

Michael Hall, 3435 Main Street, Buffalo, NY 14214

Phone: (716) 829-3316 Fax: (716) 829-2564

Notice of Privacy Practices

Authorization to Release/Obtain Health Records

Please allow two weeks for Student Health Services to process your request.

I authorize the following protected health information to be released from the health record of:

Patient’s First Name

Patient’s Last Name

Former or Maiden Name

Phone Number (with area code)

UB Person Number

Date of Birth

Year Entered UB

Year Left UB

Information to be released from your general health record

Entire record

Lab results

Office visit(s) notes

Radiology reports

Gyn visit(s) notes

Other (specify)

Immunization record

Method of disclosure

release health records FROM UB Student Health Services TO:

Name:

_____________________________________________________________

Address:

_____________________________________________________________

or Fax No.:

_____________________________________________________________

release health records TO UB Student Health Services FROM:

Name:

_____________________________________________________________

Address:

_____________________________________________________________

or Fax No.:

_____________________________________________________________

Signature of Patient (or representative authorized by law)

I understand that signing this form is voluntary.

•

Unless otherwise revoked, this authorization will expire on (date or event)

. If I fail to specify an expiration date or event, this

•

authorization is valid for one (1) year from the date of my signature.

I may revoke this authorization in writing at any time, except to the extent that UB Student Health Services has already relied on this authorization.

•

I may revoke it by sending a written notice to the Records Administrator (at the address/fax number above) stating my intent to revoke this authorization.

•

I understand that the records released may include information related to mental health.

•

I understand that the records released may include information related to HIV or AIDS.

•

I understand that the records released may include information related to the treatment for and/or /history of drug or alcohol abuse.

•

I understand that information disclosed under this authorization might be re-disclosed by the recipient and may no longer be protected by privacy laws.

•

I understand that a photocopy or facsimile copy of this authorization shall be considered as effective and valid as the original.

•

I have read and fully understand the above statements and consent to the disclosure of my health record to the extent state above.

►

Signature

►

Today’s date

Please be aware that the records you have authorized for release may include information about mental health, HIV or AIDS and/or treatment

for/history of drug or alcohol abuse. If you do not want such information to be included in this release, please write to exclude such information

on the “Special Instructions” line below (i.e. “exclude HIV information”).

Special Instructions: