Request for Review/Release of Records
Request for Review/Release of Records
Date
Date
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Name
Name
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First
Last
Phone
Phone
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Panther ID#
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Email
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FIU Email
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Date of Birth:
Date of Birth:
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DD
YYYY
The request is for (check all that apply)
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The request is for (check all that apply)
Review of Treatment Summary
Review of full record by a licensed mental health clinician
Release of Treatment Summary
Release of full record to a license mental health clinician
Compliance with court-order
Psychological Report - Cognitive/Achievement testing report
If you chose "review of full record" or "release of full record," please insert the name of the clinician and their license number here:
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Put N/A if it doesn't apply
I understand that Federal and state laws and rules prevent the release offull psychological records to students/clients,unless the release is to another licensed psychologist or is ordered by court.
If the request is for the release of records to me, I release Counseling and Psychological Services from all liability that may arise in the misplacement or disclosure of the records.
I understand that the request will be completed within a reasonable time, not to exceed 30 days.
I understand that records shall not be releasedwithout written authorization from the student/client, unless ordered by the cour
This is the description of your section break.
Draw your signature into the box below.
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Draw
or
Type
I understand this is a legal representation of my signature.
* Requests for records not made in person require notarized signature.
Clear
Full Name
I understand this is a legal representation of my signature.
* Requests for records not made in person require notarized signature.