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Office of Accessibility Services
Authorization to Disclose Health Information
1. I hereby authorize Central Connecticut State University’s Office of Accessibility Services to disclose my individually identifiable health information as described here to the person/organization named below. I understand that this authorization is voluntary and that it may include information relating to AIDS, HIV infection, behavioral health service/ psychiatric care, and treatment for alcohol and/or drug abuse.
| STUDENT'S NAME: | DATE OF BIRTH: |
| ADDRESS: | |
| CITY: STATE: | PHONE NUMBER: |
| STUDENT ID NUMBER: |
2. Dates of Service ________________________________
Are you presently a student at the University?(please circle) Yes / No
If no, when did you last attend Central? ___/ ___ (mth/yr)
Date of Graduation: (if already graduated) ___/ ___(mth/yr)
3. Information to be disclosed: (please check one or more of the following)
☐ Intake and Discharge Summaries
☐ Health/Medical Records
☐ Psychiatric Evaluations
☐ Progress Notes
☐ Treatment or Closing Summary
☐ Social Histories, Diagnoses, Prognoses, Recommendations, and All Other Similar Documentation
☐ Other (please specify): _______________________________________________
4. Please DO NOT release the following information: ____________________________ ________________________________________________________________________
5. I am requesting that this information be disclosed for the purpose of (please check one or more of the following or write “at the request of the individual” if you do not desire to state a specific reason)
☐ Determining appropriate academic/housing/other accommodations at the University
☐ Coordination of Care/Treatment
☐ Other (please specify): __________________________________________________
6. Name and address of the person(s) /organization(s) to whom the disclosure is to be made.
| NAME |
| ADDRESS |
CITY STATE ZIP CODE |
7. If disclosure is to be mailed to you, please indicate “self” in the space below or “pickup” if you wish to pick it up from our office.
Name and relationship to student of individual authorized to pick up record(s) being released from the facility:
Name: __________________________________________________ Relationship: _____________________________________________
8. I understand this authorization may be revoked in writing to Office of Accessibility Services at any time, except to the extent that action has already been taken in reliance on this authorization. This authorization shall automatically expire 1 year from the date of signature unless otherwise specified in the space provided here. DATE OF EXPIRATION: ____________________.
9. I understand that I may inspect and copy the information disclosed under this authorization and that I may receive a copy of this signed authorization form. There may be a fee associated with copying, not to exceed the amount authorized under Connecticut State law.
10. I hereby release the State of Connecticut, Central Connecticut State University, and its employees and agents from any liability arising from the disclosure to the parties designated herein of the information that Central Connecticut State University is herein authorized to disclose.
11. I understand that Central Connecticut State University’s Office of Accessibility Services may not condition treatment on the execution of this authorization except in cases of research-related treatment protocols or studies being conducted by outside third parties through Central Connecticut State University’s Office of Accessibility Services. In such cases, specific authorization for the research-related treatment protocols / studies must be signed as a condition of participation.
12. Notice to Recipients: As the recipient of this information, you may use this information only for the stated purpose. You may disclose this information to another party ONLY if there is written authorization from the student or his/her legal representative; as required or authorized by state and/or federal law.
If this disclosure contains information relating to alcohol or drug abuse education, training, treatment, rehabilitation, or research, the following shall apply: This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal regulations (Title 42 CFR Part 2) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal regulations restrict the use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
13. Notice to Individual Requesting the Disclosure:
Your signature below indicates that you understand that Central Connecticut State University’s Office of Accessibility Services is not a covered entity under the HIPAA Federal Privacy Regulations and is, consequently, not subject to those regulations.
_________________________________________________________________
Printed Name of Student
_______________________________________________________________________________
Signature of Student or Legal Representative Date
_______________________________________________________________________________
Printed name of Legal Representative* Relationship to student
* A copy of the personal representative’s legal authority to act on behalf of the student is attached.
_________________________________________________________________________
Signature of Individual Picking up Record Relationship to student
For Office Use Only
| Sign & Date |
| Check Information |
| Date records needed by: |
| Charges: |
Copy Of Authorization was provided to student: |