ࡱ> m \bjbj bbKdddddxxx8x%!  $"% d" dd Rdd  P+nDBR  0%!,&m&&d ?%!&B *:   SHAPE \* MERGEFORMAT  College Health Services AUTHORIZATION FOR THE RELEASE OF HEALTH INFORMATION NAME: ________________________________ DATE OF BIRTH: ____________ PHONE #: _____________________________ I hereby authorize and request ɬ Health Services staff to disclose the information specified below: Send Medical Records ( office notes, labs, diagnostic tests) Request Records ___________________________________ Authorize Phone discussion / E-mail correspondence For: Dates of treatment: ______________ to _______________ Condition: _______________________________________ Please release the authorized information to: (initial those that apply) _____ MHC Counseling Service _____ Athletics _____ Office of the Academic Deans _____ Disability Services _____ Parent/Guardian: __________________________Phone:________________ E-mail:________________________________________________ _____ Other: _________________________________________________________ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - These records may contain information about drug abuse, alcoholism, AIDS, alcohol abuse, sexually transmitted disease, abortion or sexual abuse. I Do DO NOT (circle one) consent to have this information disclosed. I understand that I may revoke this consent at any time, except where information has already been released. 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