Authorization for Release of Protected Health Information
Westminster College Student Health Center
Shaw Residence Hall
South Market Street
New Wilmington, Pa 16172-0001
Student Name _____________________________
I am/or have been a student at Westminster College. I understand that the facility has
legally protected health information about me. I am/was a student at Westminster from
____________________ to ______________________________.
I, _________________________________, hereby authorize Westminster College to
release _____________________________________________ to:
(information you would like released)
__________________________________________________________________
(name of individual, facility, school, to receive information)
__________________________________________________________________
(street address)
__________________________________________________________________
(city,state)
(zip code)
( phone number)
__________________________________________
Student’s signature
Date
________________________
Witness
Date