Authorization for Release of Information to the FIU Student Health Clinic

FIU Student Health Clinics ATTN: Medical Records Department 11200 SW 8 Street, SHC 150 Miami, FL 33199 Phone: (305) 348-0316 Fax: (305) 348-0336 Email: medrec@fiu.edu
Today's Date: Today's Date: / MM / DD YYYY
Student Name: Student Name: First Last
Date of Birth: Date of Birth: / MM / DD YYYY
Panther ID:
Healthcare Facility/Provider Name:
Healthcare Facility/Provider Address: Healthcare Facility/Provider Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Healthcare Facility/Provider Phone Number: Healthcare Facility/Provider Phone Number: - ### - ### ####
Healthcare Facility/Provider Fax Number: Healthcare Facility/Provider Fax Number: - ### - ### ####
Email for Healthcare Facility/Provider where to request the release my records.
I hereby authorize the healthcare facility/provider listed above to release the following information from my medical record (select all that apply):

I hereby authorize the healthcare facility/provider listed above to release the following information from my medical record (select all that apply): Entire medical record (including mental health counseling visits, substance abuse counseling, and HIV testing) Laboratory tests History and Physical Photos/Images Progress Notes Other (specify) Other (specify)
Sensitive Information: This request includes my specific permission to release the following information that is checked:

Sensitive Information: This request includes my specific permission to release the following information that is checked: Alcohol/Substance Abuse testing, treatment, and/or records Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (HIV/AIDS) testing, treatment, and/or records Sexually Transmitted Disease (STD) records which may indicate the presence of a communicable disease or non communicable disease and tests for records Genetic (Inherited) Disease testing, treatment information, and/or records Psychological, psychiatric, and other mental health treatment information, and/or records
The purpose or need for the release of this information is:

The purpose or need for the release of this information is: Continuity of care, another physician Legal/Attorney Insurance reimbursement Personal Other (specify) Other (specify)
I understand that this authorization is valid for 90 days after the date of my signature. I also understand that this authorization can be revoked, except to the extent that action has already been taken to comply with it. Information documented in my record after the date of my signature will not be released.

I understand that the information released cannot be re-disclosed by the person or institution named above unless I specifically authorize such a release in writing.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Please upload a valid government issued picture ID

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