Eastern Michigan University Health Services AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION Patient Name: ___________________________________________________________________________ Date of Birth: ________________________________ Student Number: E ______________________ I request and authorize University Health Services to release healthcare information of the patient named above _______________________________________________________________________________________ _______________________________________________________________________________________ This request and authorization applies to healthcare information relating to the following treatment, condition, or dates: _______________________________________________________________________________________ Purpose for records request: (check below) ☐ Continuation of Care ☐ Worker’s Compensation ☐ Disability Determination ☐ Employment/Prospective Employment ☐ Insurance / Billing ☐ Family/Significant Other Involvement in treatment ☐ Legal Follow­up ☐ School ☐ Other (Must Specify) __________________________________________________________________ This authorization also allows the release of the following (appropriate section must be initialed before these records are released): ___ Information about the diagnosis or testing for: 1. HIV (Human Immunodeficiency Syndrome) 2. AIDS (Acquired Immunodeficiency Syndrome) ___ Information about mental health and social services, including communications made by me to social worker or mental health professional. ___ Information about alcohol and drug abuse treatment (protected under the regulations in Code 42 of Federal Regulations, Part 2) This authorization expires six (6) months after it is signed OR as follows (insert date, condition or event): _______________________________________________________________________________________ This consent may be revoked by me in writing at any time, except for circumstances in which information has been released prior to the revocation. _______________________________________________________________________________________
Patient Signature Date _______________________________________________________________________________________
Witness Signature Date NOTICE OF FEDERAL AND STATE LAW AGAINST FURTHER DISCLOSURE TO THE PERSON OR ORGANIZATION RECEIVING INFORMATION “This information may have been disclosed to you from records whose confidentiality is protected by federal and state laws. Federal regulations (42 CFR, Part 2) and state laws (Public Act 258, Chapter 7, Section 748) prohibit you from making any further disclosure of it 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 this purpose. For Health Center use only Completed by: ____________________ Date completed: ________ Delivery method: ☐ Faxed ☐ Mailed ☐ In Person