Authorization for Release of Health
Name of Patient: _______________________________ _ (Name of College or University)
Student ID #_________________________ Student Health & Counseling Services
One Shields Avenue
Birth date: _____________________________ Davis, CA 95616
(List Phone Number and Fax)
Authorization for Release of Health Information
I hereby authorize: (Name of person and/or facility that has such information) of (street
address, city, state, zip code), to release health information to: (Specify name and title of
person or name of facility to receive the health information).
Type of Disclosure [ ] Copies [ ] Verbal [ ] Inspection [ ] Summary
Please specify the health information you authorize to be released. :
[ ] Medical (may include mental health notes).
[ ] Mental Health (other than psychotherapy notes)
Types of health insurance information to be disclosed:
[ ] All immunizations: __________________________________________________
[ ] Specific health information: _______________________________________
Date(s) of treatment: ________________________________________________________ _
The following information will not be released unless you specifically authorize it by
marking the relevant box(es) below: .
[ ] I specifically authorize the release of information pertaining to drug and alcohol
abuse, diagnosis or treatment (42 C.F.R. 2.34 and 2.35).
[ ] I specifically authorize the release of HIV / AIDS test results (Health and Safety Code
[ ] I specifically authorize the release of genetic testing information (Health and
Safety Code 124980 .
The purpose of this release is for (check one or more):
[ ] At the request of the patient/patient representative
[ ] Other (state reason) _________________________________________________________