ࡱ> JLIo bjbj;; *2QvfQvfF<<BBBVVVVD$V$'0wCh&&&&&&&$(+&B4$w|4$4$&&%%%4$RB&%4$&%%& ";&J$:+&&&0$'3&",$",;&",B;&TU0% y!&&6%|$'4$4$4$4$",<X :  Ģý UHS Box 270356 UNIVERSITY COUNSELING CENTER Rochester, NY 14627 www.rochester.edu/ucc River Campus (585) 275-3113 Fax: (585) 442-0815 Authorization for Release of Information Name: _____________________________________________ Date of Birth: ________________________________ Address: ___________________________________________ City, State, Zip: ______________________________ Student ID#: _______________________ Student Phone Number: ________________________________________  FORMCHECKBOX  I authorize the University Counseling Center  FORMCHECKBOX  I authorize the University Counseling Center to release information to: to obtain information from:  ______________________________________ _______________________________________ Name of Provider or Facility Name of Provider or Facility ______________________________________ _______________________________________ Address Address ______________________________________ _______________________________________ City, State, Zip Code City, State, Zip Code ______________________________________ _______________________________________ Phone #/Fax # (Include area code) Phone #/Fax # (Include area code) PURPOSE OF THIS REQUEST: (check one)  FORMCHECKBOX  Healthcare  FORMCHECKBOX  Insurance Coverage  FORMCHECKBOX  Personal  FORMCHECKBOX  Other TYPE OF RECORDS AUTHORIZED:  FORMCHECKBOX  Psychiatric/Psychological Evaluation and/orTreatment  FORMCHECKBOX  Drug/Alcohol Evaluation and/orTreatment SPECIFIC INFORMATION AUTHORIZED: (select one or more as appropriate)  FORMCHECKBOX  Assessments  FORMCHECKBOX  Progress Notes  FORMCHECKBOX  Laboratory Test Results: ________________________________  FORMCHECKBOX  Diagnostic Impression  FORMCHECKBOX  Discharge Summary  FORMCHECKBOX  Treatment Plans  FORMCHECKBOX  Treatment Summary  FORMCHECKBOX  Other: (please describe)______________________________________________________ One-time Use/Disclosure: I authorize the one-time use or disclosure of the information described above to the person/provider/organization/facility/program(s) identified. My authorization will expire:  FORMCHECKBOX  When the requested information has been sent/received.  FORMCHECKBOX  90 days from this date.  FORMCHECKBOX  Other: __________________________________________ Periodic Use/Disclosure: I authorize the periodic use/disclosure of the information described above to the person/provider/organization/facility/program(s) identified as often as necessary to fulfill the purpose identified in this document. My authorization will expire:  FORMCHECKBOX  When I am no longer receiving services from the University Counseling Center.  FORMCHECKBOX  One year from this date.  FORMCHECKBOX  Other: ____________________________________   Signature of Student or Representative: _________________________________________ Date: __________________ Relationship to Student (if requester is not the student):  FORMCHECKBOX  Parent  FORMCHECKBOX  Legal Guardian  FORMCHECKBOX  Other: ____________________________ Patient or Representative has been provided a copy of this authorization: ___________________________________________________ Staff member providing copy Records request reviewed by ___________________________________________________________Date_______________________ Forms\Release of Information.doc Revised 10/18/13 AND/OR I understand that: I do not have to sign this authorization and that my refusal to sign will not affect my abilities to obtain treatment. I may cancel this authorization at any time by submitting a written request to the University Counseling Center, except where a disclosure has already been made in reliance on my prior authorization. If the person of facility receiving this information is not a health care or medical insurance provider covered by privacy regulations, the information stated above could be redisclosed. If the authorized information is protected by Federal Confidentiality Rules 42CFR, Part 2, it may not be disclosed without my written consent unless otherwise provided for in the regulations. Release of HIV-related information requires additional information. 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