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Authorization for Release of Medical Information
I hereby authorize the release of information from the medical record of:
Patient Name: __________________________________ Date of Birth: __________________________
Social Security #: _____________________ STMU ID#__________________ Daytime Phone #: _______________
Information Released To: From:
________________________________________ __________________________________________
________________________________________ __________________________________________
________________________________________ __________________________________________
Please Release the Following:
_____ Problem List _____ X-Ray Reports
_____ Progress Notes _____ X-Ray Films
_____ History/Physical Exam _____ EKG Reports
_____ Lab Reports _____ Other Diagnostic Reports (Specify) ___________
_____ Immunizations _____ Other (Specify) ___________________________
Including information (if applicable) pertaining to:
_____ Mental Health _____Drug/Alcohol _____HIV/AIDS _____Communicable Treatment
Purpose of Need for Disclosure:
_____Continued Patient Care _____ Personal Use
_____ Attorney/Legal _____ Insurance Claim/Application
_____ Disability Determination _____ Other (Specify)
I understand that the information released is for the specific purpose stated above. Any other use of this information without the
written consent of the patient is prohibited. I further understand that I may revoke this consent (in writing) at any time except to the
extent that action has been taken in reliance on it. This consent will expire 90 days after the date of my signature unless otherwise
specified.
___________________________________ _____________________
Signature of Patient or Legal Representative Date
___________________________________ _____________________
Relationship to Patient Witness
COMPLETE ONLY IF INFORMATION IS TO BE RELEASED DIRECTLY TO PATIENT:
I understand that my medical record may contain reports, test results, and notes that only a physician can interpret. I understand and
have been advised that I should contact my physician regarding the entries made in my medical record to prevent my
misunderstanding of the information contained in these entries.
I will not hold St. Mary’s University Student Health Center liable for any misinterpretation of the information in my medical record as
a result of not consulting my physician for the correct interpretation.
____________________________________ _______________________
Signature of Patient or Legal Representative Date
____________________________________ _______________________
Relationship to Patient Witness
Date request completed________ # pages copied ________ Initials ________
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