Medical Records Release Form
Bloomsburg University
Student Health Center
(570) 389-4451
Room 324 Kehr Union Building
400 E. Second Street
Bloomsburg, PA 17815
____________________________________________________________________
_________________________________
Student’s Name (Please Print)
BU ID#
(_________)_________________________________________
_________________________________
Telephone #
Date of Birth
I do hereby consent and authorize Bloomsburg University’s Student Health Center to disclose/ release copies of the
following information from my Student Health Center medical records:
o Immunization record(s)
○ Tuberculosis Skin Testing (TST) records
o Health Form
○ Physical
o Laboratory reports (specify)_____________________________________________________________________
o X-ray reports (specify)_________________________________________________________________________
o Clinic Notes (List Dates) _______________________________________________________________________
o Other (specify)___________________________________________________________
o I give permission for the Student Health Center staff to verbally discuss the indicated medical information
with_______________________________________________________.
I understand that records and reports generated by other medical facilities cannot be copied and released to me (for
example: Emergency Room reports). To obtain these reports, I must request copies from the originating medical
facilities.
This Information Will Be Released To:
Name
________________________________
Address ______________________________________________________
___________________________________________________________________________________________________________
Telephone # (________)________________________________
_______I will pick up the records
Fax# (________)_________________________________
_______Mail the records
______Fax the records
I understand that I have the right to inspect material that is to be released. I understand that I may revoke this
authorization at any time by notifying the Student Health Center. However, this authorization shall be effective
immediately and shall expire in 60 days from the authorization.
_________________________________________________
*Student’s Signature
__________________
Date
**Special Authorization**
I authorize Bloomsburg University’s Student Health Center to release information related to the testing, diagnosis and/or
treatment for any of the following conditions to the person(s) listed above. Student, please date and sign your name in
front of the section which describes the type of information you wish to be released.
Information concerning my mental health/neuro-psychological condition.
Information concerning my drug abuse and related health problems.
Information concerning my HIV/AIDS condition and related health problems.
Information concerning my eating disorder(s) and related problems.
Other (Specify)__________________________________________________
OFFICE USE ONLY
Student Name____________________________________
BU ID#_________________________
Date Records Processed:______________________
By (initials):_____________
() Pick-up:___________ Mailed:___________ Faxed:___________
P&P.Medical Records Release Form.0512.docx