AUTHORIZATION TO RELEASE MEDICAL INFORMATION Beu

AUTHORIZATION TO RELEASE MEDICAL INFORMATION Beu Health Center

1 University Circle, WIU

Macomb, IL 61455

Phone (309) 298-1888

FAX (309) 298-2188

PATIENT NAME (Please print):

Last Name First Name MI Date of Birth

Address

9-digit WIU Student ID # Local Phone

RELEASE FROM: RELEASE TO:

Beu Health Center

Name: _________________________________

Beu Health Center

Name: _______________________________

Address City Address City

State Zip FAX State

Zip

FAX

PURPOSE: DATES OF RECORDS TO BE RELEASED:

Patient’s Request Continuing Treatment

Legal Insurance Other :

From: _____/_____/________ To: _____/_____/________

SPECIFY RECORDS TO BE RELEASED:

Allergy Records X-ray report X-ray CD Physical Exam Laboratory Results Immunization records

TB tests Clinic Notes Other (Specify): __________________________________________

Entire Health Record ($20.00 Charge applies). There is no charge to mail health record to another healthcare professional (e.g. physician). Entire health

record will not be faxed.

By initialing the boxes below, I am authorizing the release of the following information:

_____ Alcohol and/or drug abuse treatment information (as protected under 42 CFR)

_____ HIV/AIDS Information (as defined by Illinois Statute)

_____ Mental Health Records (as defined by the Illinois Mental Health and Developmental Disabilities Confidentiality Act)

This consent will terminate upon (specific date, event or condition): ____________________________________. I understand that I may revoke this consent at any time except to the extent that the

program or person which is to make the disclosure has already acted in reliance on it. Acting in reliance includes the provision of treatment services in reliance on a valid consent to disclose

information to a third party payer. If no calendar date is specified above, Mental Health Records may only be released on the date this release is received by our office.

NOTICE TO PATIENT:

I fully understand that my medical record and health information for the above date(s) may contain alcohol/drug abuse, and/or HIV/AIDS test results, mental health

information and/or other information.* I understand that any of the above selected records may contain medical information from outside sources and authorize Beu Health

Center to release these records and health information if necessary for the continuity of care or if I have requested my complete record. I understand that I have the right to

inspect and/or obtain a copy (for the appropriate fee) of my medical record prior to disclosure. I understand that this consent applies both to written and verbal release of

information. I absolve, discharge, release, & hold harmless the Board of Trustees for Western Illinois University together with its agents and employee for any legal liability,

claims, or damages which may arise from the disclosure of this information.

* To receiving agency: these records may not be re-disclosed without the patient’s consent.

_____________________________________________________ ___________________________________

Signature of patient or authorized legal guardian Date

_____________________________________________________ ___________________________________

Relationship to patient, if signed by authorized representative Date

_____________________________________________________ ___________________________________

Witness signature (required for mental health/HIV/substance abuse) Date

FOR OFFICE USE ONLY:

Date prepared: Date Mailed/Faxed: Date given to student: Fee:

Initials: Initials: Initials: Green Task Completed?

Rev.09.10