Hanover College : Counseling Services : Authorization for Release of Health Information

Authorization for Release of Health Information

This form allows you to authorize the release of your information to other persons or organizations involved in your care.

This person may be a friend or a relative, a medical professional, or your hometown therapist.

Your Information

Date of birth:

- -

Graduation year:

Phone number:

Person Recieving Information

Provide the contact information for the person to release your information to:

Name:

Address:

Phone number:

Fax number:

Type Of Records

Please indicate the type of information to release:

I authorize Counseling Services to release my mental health information.

I authorize Counseling Services to release information regarding my drug or alcohol treatment.

I authorize Counseling Services to release information regarding my sexually transmitted disease information (inlcuding HIV/AIDS).

Specific medical information:

Reason For Release

Please select all the reasons for the release of your information:

Facilitate treatment/coordination of care

Re-admission

Other reason:

By submitting this form you acknowledge and consent to the following:

Counseling Services to release your information to the person you indicated on this form. This authorization expires one year from today (05/20/2025) and that you may revoke this authorization at any time by contacting Counseling Services. The revocation will be effective on the date of receipt.
Upon release and disclosure of the protected medical records and information, the records and information may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations.