Authorization for Medical Release

Patient Name*

First Middle Last

Date of Birth*

Email Address*

Start Year Attended BU

Ex. 2014

End Year Attended BU

Ex. 2019

BU ID #*

Telephone Number (Domestic Only)

Purpose of Disclosure:*

Which Medical Records would you like to release?*

Primary Care/General Medicine/Sports Medicine Medical Records
Counseling Medical Records

Primary Care/General Medicine/Sports Medicine Medical Records Only:*

Entire Medical Records (This includes sensitive information)
Other

By selecting the entire record option, I understand that if my medical record contains information in reference to drugs and/or alcohol abuse, psychiatric, venereal disease, social service, Hepatitis B testing/treatment and HIV (AIDS) testing/treatment records released/or sensitive information, I agree to the release of this information by submitting this form.

Counseling Medical Records Only:*

Entire Medical Records (This includes sensitive information)
Other

By selecting the entire record option, I understand that if my medical record contains information in reference to drugs and/or alcohol abuse, psychiatric, venereal disease, social service, Hepatitis B testing/treatment and HIV (AIDS) testing/treatment records released/or sensitive information, I agree to the release of this information by submitting this form.

If "Other" is selected above then please include a description of specific information to be disclosed:*

Release Information to:*

Self (Same as Patient Name)
Other

I request that the records/health information be sent by:*

Secure Encrypted Email
Fax

Name or Organization*

Secure Email Address*

Name or Organization*

Fax Number*

Address*

Address 1 Address 2 City State ZIP Code

I understand that: I may revoke this Authorization at any time by providing a written notice of revocation as specified by the Notice of Privacy Practice; however such revocation will not affect any action taken in reliance on this Authorization before receipt of my written revocation. Treatment, payment, enrollment in a health plan or eligibility for benefits will not be conditioned on whether I provide this Authorization for any requested use or disclosure of health information unless (a) the treatment is research related, (b) the information is needed for health plan eligibility or underwriting determinations, or (c) the sole purpose of creating the information is to disclose it to a third party. The information used or disclosed pursuant to this Authorization, except information protected by federal regulations about confidentiality of drug and alcohol abuse records, may be subject to re-disclosure by the recipient and no longer protected by federal privacy regulations or other applicable state or federal laws.

Electronic Signature*

I have carefully read and I understand this Authorization form. I have had any questions explained to my satisfaction. I expressly and voluntarily authorize and request the disclosure of the above named patient’s health records and information to Student Health Services of BU.

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