APPENDIX D
STUDENT CONSENT FOR ACCESS TO TREATMENT RECORDS
HEALTH SERVICES AND ACCESSIBILITY SERVICES
Name of Student (Last, First, Middle Initial):
Student ID:
Date:
The Family Educational Rights and Privacy Act (FERPA) affords certain rights to students concerning the privacy of, and access to, their
treatment records. Students may choose to complete and submit this form to Health Services or Accessibility Services allowing the
release of their treatment records to specified third parties. Please note that while this form authorizes the University of West Georgia
to release records to third parties, it does not obligate UWG to do so. UWG reserves the right to review and respond to requests for
release of treatment records, or information contained therein, on a case-by-case basis. For additional information, visit UWG’s FERPA
Information page at this site or the U.S. Dept. of Education’s website at this site. Please note that FERPA provides that your records
may be released without your consent under certain circumstances.
EDUCATION RECORDS [REFER TO FORM “Student Consent for Access to Education Records”]
SECTION A. TREATMENT RECORDS to be released include but are not limited to the following categories.
(Check all that apply):
☐ Student Health Services/Medical Records (history and physical exams, physicians orders, medication and treatment records,
reports from lab, x-rays and other diagnostic tests, including correspondence and administrative documents.)
☐ Student Behavioral/Disability/Mental Health Records (mental health history and exams, physicians orders, medication and
treatment records, reports and other diagnostic tests, including correspondence and administrative documents.)
SECTION B. TREATMENT RECORDS that I do not wish to be released:
Please list any treatment records that you would prefer not to be included, or check the box if you give consent to the disclosure of
all treatment records from Section A.
☐I give permission to release all records.
SECTION C. Person(s) to whom access to education records may be provided:
___________________________________________________________________________________________________________
Name(s) of person(s) to whom access to records may be provided
___________________________________________________________________________________________________________
Address of person(s) to whom access to records may be provided
Relationship to Student
SECTION D. Create a PIN Access Code (must include two letters and three numbers(ex. ZZ111)
PIN ACCESS CODE: ________________ (share this code only with the person listed above.
The university will ask for this access code as a form of identifying the individual(s) listed in section B.)
SECTION E. Duration of release (check one):
☐One-Time Use: This authorization can be used only once as of date of form.
☐Permanent or Limited Use: This authorization expires on:_________________________________________________
SECTION F. Purpose of release (check one):
☐ Family Communications
☐ Employment
☐ Other (please specify):___________________________________________________________________________
I understand that (1) I have the right not to consent to the release of my education records, (2) I have the right to inspect any written
records released pursuant to this consent, and (3) I have the right to revoke this consent at any time by delivering a written revocation
to the Enrollment Services Center.
___________________________________________________________________________________________________________
Student’s Signature
(Date)
Instructions for Completion of this Form, and Exceptions to Disclosures on Page Two:
Created July 1, 2014
APPENDIX D
STUDENT CONSENT FOR ACCESS TO TREATMENT RECORDS
HEALTH SERVICES AND ACCESSIBILITY SERVICES
Page Two
Instructions for completing this form:
1. The form must be fully completed and signed by the student. Records cannot be released if any section of this form is not filled out entirely.
2. Completed forms may be mailed to the Health Services Center, University of West Georgia, 1601 Maple Street, Carrollton, GA 30118, via fax (678)
839-0656. All questions about this form may be directed to the Health Services Center at (678) 839-6452
This information is released subject to the confidentiality provisions of appropriate state and federal laws and regulations which prohibit any further
disclosure of this information without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations.
EXCEPTIONS:
Birth Certificates An official document issued to record a person’s birth, including such identifying data as name, gender,
date of birth, place of birth, and parentage
Social Security Card (SSN) A nine-digit number assigned to citizens, some temporary residents and permanent residents in
order to track their income and determine benefit entitlements. The Social Security number was created in 1936 and
while the original intention was just to track earnings and benefits, it is now also used to identify individuals and
sometimes track their credit record.
Passport and Visas is a document certifying identity and nationality.
Federal and/or State Income Tax records
Form W-2, Wage and Tax Statement used to report wages paid to employees and the taxes withheld from them.
Driver’s License
The DD Form 214, Certificate of Release or Discharge from Active Duty, generally referred to as a "DD 214", is a
document of the United States Department of Defense, issued upon a military service member's retirement, separation,
or discharge from active-duty military.
Created July 1, 2014