Alabama A&M University
Office of Health & Counseling Services
Student Release Authorization
Patient Name: ____________________________________________________________________ SS#:
DOB:
Phone #:
Address:
City:
State:
Zip:
I____________________________________________hereby authorize Alabama A&M University Student Health Center to release/request the following
information:
Academic testing results
Treatment plans
Psychological testing results/reports
Progress reports
Summary reports
Vocational testing results
Intelligence testing results
Medical records
*Psychotherapy notes
Entire record, except progress notes
Other, specify
*A SEPARATE AUTHORIZATION, AS DEFINED BY HIPAA, IS REQUIRED FOR *PSYCHOTHERAPY NOTES AND DETAILED PATIENT NOTES.
The specific purpose and need for this disclosure is:
This release is voluntary and automatically expires after one year. Cancellation of request to release requires written notice. You have a right to refuse to sign this release. Unless the
patient wishes to cancel the release at an earlier time, it will automatically stop upon the date and/or condition as indicated below:
Date:
Event/Condition
I understand that this information is protected by Title 42 (Code of Federal Rules of Privacy of Individually Identifiable Health Information, Parts 160 and 164) and Title 45 (Federal
Rules of Confidentiality of Alcohol and Drug Abuse Patient Records, Chapter 1, Part 2), plus applicable state laws. I further understand the information disclosed to the recipient may
not be protected under these guidelines if they are not a health care provider covered by state or federal rules.
Your relationship to student: Self
Parent/legal guardian
Personal representative
Other (describe)
If you are the legal guardian or representative appointed by the court for the client, please attach a copy of this authorization to receive
this protected health information.
Patient Signature:
Date:
/
/
Staff Signature:
Date:
/
/
NOTICE TO PARTY RECEIVING INFORMATION: This information has been disclosed to you from records, whose confidentiality is protected by federal law, which prohibits you from
making any further disclosure of information without the specific written consent of the person to whom it pertains, or as otherwise permitted, by such regulations. A general
authorization for the release of medical or other information is NOT sufficient for that purpose.