Authorization to Request Medical Information Be Sent to the Heath Center:
Authorization to Request Medical Information To Be Sent to the Student Health Center:
(Request Records from Another Provider to be sent to the Student Health Center)
- General Release of Information Form
- Specific Type of Service Being Requested: (Please click the appropriate link below to download and print out the form for the type of service being requested.)
- In order to provide better customer service to Health Center patients, the Health Information Management (HIM) Staff can request copies of your medical record from other medical providers when seeking these types of services. An authorization to release medical information must be signed and dated by the patient or the patient's legal guardian.
- All sections of the form should be completed; including initials to applicable information in section #4 and sign/date. Please note, the SHC does not accept electronic signatures.
- The completed form should be faxed to the Provider you specified in Section #1.
- The turnaround time to receive copies of health information will depend on how quickly your Provider sends the requested records to the Health Center HIM Department.
Please direct any questions about the Release of Information process to the Health Information Management Department at the Student Health Center; 512.245.8437.