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Delaware Authorization for Use or Disclosure of Protected Health Information Form

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Delaware Authorization for Use or Disclosure of Protected Health Information Form
Delaware Authorization for Use or Disclosure of Protected Health Information Form
Revised 11/13
C/M-05a
1499615.1 11/22/2013
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
Please Print
PATIENT NAME___________________________________________________ UD ID #_____________________
CURRENT ADDRESS________________________________________________________________________________
TELEPHONE___________________________________ DATE OF BIRTH_________________________________
I hereby authorize the University of Delaware Student Health Service to release to:
NAME ____________________________________________________________________________________________
ADDRESS ________________________________________________________________________________________
TELEPHONE ______________________________________ FAX ______________________________________
Check appropriate line:
_____ Immunization/PPD Results & associated chest X-ray only (Does not require administrative signature for release)
_____ Diagnostic test results only:
Type(s) _________________________________________Dates_________________________________
_____ Gynecology record only
_____ Partial medical record related to my problem with ______________________ from ________ to___________
_____ Whole medical record while attending the University of Delaware (Including treatments 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 ______________
PRINT NAME __________________________________________________________________
If not signed by the patient, indicate your relationship/authority to sign for the patient ___________________________________________________
=========================================================
ID VERIFICATION _______ YES _______ NO SHS WITNESS _____________________________________
APPROVAL OF STUDENT HEALTH SERVICE DIRECTOR OR ASSISTANT DIRECTOR FOR NURSING SERVICE:
______________________________________________________________________________________
Records were
SENT TELEPHONED FAXED GIVEN to Authorized Entity/Individual listed above by:
Name ____________________________________ Title ____________________ Date __________ Time __________
Delaware Authorization for Use or Disclosure of Protected Health Information Form