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					               FORDHAM UNIVERSITY STUDENT HEALTH SERVICES

         Rose Hill                                                                         Lincoln Center
        441 E. Fordham Road                                                                155 West 60th Street
        Bronx, NY 10458                                                                    New York, NY 10023
        718) 817-4160                                                                      (212) 636-7160
        (718) 817-3218 FAX                                                                 (212) 636-7164 FAX


                       AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

Patient Information

Patient Name: ________________________________                    Birth date: ______________________
Student ID #:______________________________ Cell Phone:___________________
Address: __________________________________________________________________________________

Release From: (Name of Facility or Clinician Releasing Information)
I authorize release of my medical records from:
Facility/Name of Clinician:  FORDHAM UNIVERSITY  Other (Specify) ___________________________
Address: (if different from Fordham facility):____________________________________________________
Release To: (Name of Facility/Clinician/Person Receiving Information)
Please send my medical records to:
Name:__________________________                                   Telephone #:__________________
Complete Address:_____________________________________ Fax #:__________________
Release Information:
Reason:  Moving out of area          Transfer of care  Legal        Ins Reimbursement
         Requirement for school  Specialist consult  Personal file
Please release the following: (check all that apply)
        Immunizations
        Clinic Visits (Specify) ___________________________
        Gynecological Exams (including PAP smears)      HIV Test Result(s) (Initials)________
        Laboratory Results Only (Specify)_________________
        Other Information (Specify) ___________________________________________________________
Consent:
This information is intended by the above named recipient only. I am aware that the records released may contain
information relating to a psychiatric or psychological testing, physical abuse, or drug and alcohol abuse. This
authorization will expire exactly one year from the date below or on __________. I have a right to receive a copy of this
authorization. I may revoke this authorization at any time in writing. I understand that information used or disclosed under
this authorization may be subject to re disclosure by the recipient without being further protected under the
HIPPA/FERPA rules.

I understand that I may be charged for copies provided.

Signature of Patient: _____________________________________ Date:______________________
Witnessed by __________________________________________ Date:______________________


FOR OFFICE USE ONLY:  Approved  Not Approved            Date:________   Disposition:________________________________

				
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posted:10/3/2012
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