UNIVERSITY OF CALIFORNIA, SAN DIEGO
Student Health Services (MC 0039)
9500 Gilman Drive, La Jolla, CA 92093
Phone: (858) 534-2139
E-mail: shsmr@ucsd.edu
Fax:
(858) 534-7545
AUTHORIZATION TO RELEASE OR EXCHANGE CONFIDENTIAL INFORMATION
Note: SHS does not accept or send medical records via e-mail, or correspond by fax or mail out of the U.S.
I, _______________________________________________ Student ID: __________________
(Student’s Name/Legal Representative)
Birth Date: __________________
Hereby authorize UCSD Student Health Service to:
Release information to:
Obtain information from:
Exchange verbally with:
.
Name:
____________________________________________________________
Address:
____________________________________________________________
Telephone: _________________________ Fax: _______________________________
Specific information to be released: (please initial each category that applies)
_____
_____
_____
_____
Visit Notes Only
____ X-ray/Labs Only
Immunizations Records Only
____ Billing Records Only
All Medical Records
Other as specified: ___________________________________________
Sensitive Issues: You must specifically authorize the disclosure of the following types of information.
Initial each item that applies:
_____ HIV/AIDS information
_____ Drug/Alcohol/Substance Abuse Diagnosis/Treatment
_____ Genetic Test Results
_____ Gender Issues
_____ Mental Health (does not inlcude CAPS records)
For the following purpose(s):
_____ Coordination of treatment/care
_____ Administrative and/or Academic Coordination
_____ Other ______________________________________________________________
NOTICE: UCSD Student Health Services, and other health care providers and organizations such as
physicians, hospitals and health plans, are required by law to keep your health information confidential.
If you have authorized the disclosure of your health information to someone who is not legally required
to keep it confidential, it may no longer be protected by state or federal confidentiality laws.
I understand that I can obtain a copy of this authorization. A copy of this form is as valid as the original. I
understand that I have the right to refuse to sign this form, and that I may revoke my consent at any time
(except to the extent that the information has already been released.) This revocation must be delivered
in writing to each of the treatment providers listed above.
THIS CONSENT WILL AUTOMATICALLY EXPIRE ONE YEAR FROM DATE OF YOUR SIGNATURE
___________________________________________ (electronic signature
(Student’s signature or Legal Representative)
is not accepted)
____________
(Date)
___________________________________________
(Printed Name)
If you require copies of your records from Student Health Services, please complete reverse side of this form.
MEDICAL RECORDS REQUEST FORM
FROM UCSD STUDENT HEALTH SERVICES
Patient Name: ____________________________________________________________________
Former Name: ____________________________________________________________________
Address: _______________________________________________________________________
Street
City
State
Zip
Phone Number: _____________________________ e-mail: _____________________________
Note: SHS does not accept or send medical records via e-mail, or correspond by fax or mail out of the U.S.
Check one of the following:
I request my records to be faxed to the party named on the reverse side at
Fax Number: ________________________________________________
I request my records to be mailed to the party named on the reverse side
I will pick up copies of my records
Third party pick up only – Name: __________________________________
PID# _______________________ License #: ______________________
*Fee Charges for Copying Records at Student Health Service:





Electronic Medical Records (onsite): first 4 pages free, each additional page
$0.20 each, plus $5.00 Administrative Fee
Archived Chart Records (offsite): first 4 pages free, each additional page $0.20
each, plus $5.00 Administrative Fee + $9.50 Recovery Fee
Mail Fee: $5.00 applied any time requests are mailed from SHS
Vaccine Records: one copy provided at no cost every six months (registered
students only); onsite record charge effective for additional requests
Records to outside physicians or health facilities – no charge
Note: Once you submit this authorization you have (1) one business day to revoke your request.
Thereafter you will be responsible for all fees incurred by your request.
Would you like the total fee amount?
Yes
No
_______________________________________
(Student’s signature or Legal Representative)
_______________________________________
(Print Name if different than patient name)
MedRelease 10162015
By:
Email
Phone
__________________
(Date)