Delaware Authorization For Use Or Disclosure Of Protected Health Information Form Preview
Microsoft Word - Auth to Release PMI.docx
University of Delaware, Student Health Service
Laurel Hall Newark, DE 19716-8101
(302) 831-2226 Fax (302) 831-6407
AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION
PATIENT NAME UD ID # CURRENT ADDRESS
TELEPHONE DATE OF BIRTH
I hereby authorize the University of Delaware Student Health Service to release to:
Check appropriate line:
Immunization/PPD Results & associated chest X-ray only (Does not require administrative signature for release)
Diagnostic test results only:
Gynecology record only
Partial medical record related to my problem with from to
Whole medical record while attending the University of Delaware (Includingtreatments for sexually transmitted diseases, pregnancy, gynecology visits, HIV counseling/testing information, and drug or alcohol diagnosis/treatment/referral information.)
Illness Verification letter from Student Health Service Director to College of related to my problem with from (date)to (date)
Reason for Disclosure
I understand that this request for release of information stands effective for 120 days from the date it is signed or until
. I may revoke this Authorization at any time. I understand that my revocation must be in writing, signed by me or on my behalf, and delivered to: University of Delaware, Student Health Service, Laurel Hall, Newark, DE 19716-8101. My revocation will be effective upon receipt, but will not be effective to the extent that the University of Delaware Student Health Service has taken action in reliance upon this Authorization.
Disclosure of specific information authorized for release is limited to the above-mentioned recipient only.
I understand that treatment, payment, enrollment or eligibility for benefits at University of Delaware Student Health Service cannot be conditioned on the signing of this authorization.
I also understand that once released, University of Delaware Student Health Service has no control over any re-disclosure of my records that may occur, and my information may be subject to redisclosure by the recipient and no longer protected by law.
SIGNATURE DATE TIME
If not signed by the patient, indicate your relationship/authority to sign for the patient