Release of Medical Information
For the blank Release of Information form please fill out:
- Patient Information completely
- Who will be releasing information and who will be receiving information (check to release to or to obtain from box)
- What information you want to be released (be as specific as possible)
- Mark in box for specific records that need special permissions (i.e. Mental Health Records)
- Select the Purpose for releasing
- Sign and Date the document
- Signature must be signed- cannot be typed onto signature line
Return completed form to clinic or scan in completed document and email to firstname.lastname@example.org
Download Blank Release of Information here.
Select prepopulated Release of Information for Student Health Service to release to another facility/person.
Download Prepopulated Release of Information here.
If you are 18 or older, your medical information is confidential. As your health care provider, we are legally required to protect the privacy of your health information.