{"id":1941,"date":"2025-06-03T15:41:31","date_gmt":"2025-06-03T19:41:31","guid":{"rendered":"https:\/\/www.bu.edu\/shs\/?page_id=1941"},"modified":"2025-06-03T15:41:31","modified_gmt":"2025-06-03T19:41:31","slug":"authorization-for-medical-release-form","status":"publish","type":"page","link":"https:\/\/www.bu.edu\/shs\/authorization-for-medical-release-form\/","title":{"rendered":"Authorization for Medical Release Form"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_10' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Authorization to Release Medical Information<\/h2>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_10'  action='\/shs\/wp-json\/wp\/v2\/pages\/1941' data-formid='10' >\n                        <div class='gform-body gform_body'><div id='gform_fields_10' class='gform_fields top_label form_sublabel_below description_below'><fieldset id=\"field_10_1\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_1\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Patient Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_10_1'>\n                            \n                            <span id='input_10_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_10_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_10_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_10_1_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.4' id='input_10_1_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_10_1_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_10_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_10_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_10_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_10_2\"  class=\"gfield gfield--type-date gfield--input-type-datedropdown gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_2\"><legend class='gfield_label gform-field-label'  >Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_10_2' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_10_2_1_container'><select name='input_2[]' id='input_10_2_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_10_2_2_container'><select name='input_2[]' id='input_10_2_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_10_2_3_container'><select name='input_2[]' id='input_10_2_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><div id=\"field_10_40\"  class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_40\"><label class='gfield_label gform-field-label' for='input_10_40' >Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_40' id='input_10_40' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_10_51\"  class=\"gfield gfield--type-text gf_left_half gfield--width-half field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_51\"><label class='gfield_label gform-field-label' for='input_10_51' >Start Year Attended BU<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_10_51' type='text' value='' class='small'  aria-describedby=\"gfield_description_10_51\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_10_51'>Ex. 2014<\/div><\/div><div id=\"field_10_52\"  class=\"gfield gfield--type-text gf_right_half gfield--width-half field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_52\"><label class='gfield_label gform-field-label' for='input_10_52' >End Year Attended BU<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_10_52' type='text' value='' class='small'  aria-describedby=\"gfield_description_10_52\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_10_52'>Ex. 2019<\/div><\/div><div id=\"field_10_4\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_4\"><label class='gfield_label gform-field-label' for='input_10_4' >BU ID #<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_10_4' type='text' value='' class='medium' maxlength='9'    aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_5\"  class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_5\"><label class='gfield_label gform-field-label' for='input_10_5' >Telephone Number (Domestic Only)<\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_10_5' type='text' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_7\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_7\"><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_10_17\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_17\"><legend class='gfield_label gform-field-label'  >Purpose of Disclosure:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_17'>\n\t\t\t<div class='gchoice gchoice_10_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Medical Treatment'  id='choice_10_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_17_0' id='label_10_17_0' class='gform-field-label gform-field-label--type-inline'>Medical Treatment<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Insurance'  id='choice_10_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_17_1' id='label_10_17_1' class='gform-field-label gform-field-label--type-inline'>Insurance<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_17_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Legal Reasons'  id='choice_10_17_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_17_2' id='label_10_17_2' class='gform-field-label gform-field-label--type-inline'>Legal Reasons<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_17_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Personal'  id='choice_10_17_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_17_3' id='label_10_17_3' class='gform-field-label gform-field-label--type-inline'>Personal<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_17_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='gf_other_choice'  id='choice_10_17_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_17_4' id='label_10_17_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_10_17_other' class='gchoice_other_control' name='input_17_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_37\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_37\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Which Medical Records would you like to release?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_10_37'><div class='gchoice gchoice_10_37_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.1' type='checkbox'  value='Primary Care\/General Medicine\/Sports Medicine Medical Records'  id='choice_10_37_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_37_1' id='label_10_37_1' class='gform-field-label gform-field-label--type-inline'>Primary Care\/General Medicine\/Sports Medicine Medical Records<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_37_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.2' type='checkbox'  value='Counseling Medical Records'  id='choice_10_37_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_37_2' id='label_10_37_2' class='gform-field-label gform-field-label--type-inline'>Counseling Medical Records<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_58\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_58\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Primary Care\/General Medicine\/Sports Medicine Medical Records Only:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_10_58'><div class='gchoice gchoice_10_58_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.1' type='checkbox'  value='Entire Medical Records (This includes sensitive information)'  id='choice_10_58_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_58_1' id='label_10_58_1' class='gform-field-label gform-field-label--type-inline'>Entire Medical Records (This includes sensitive information)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_58_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.2' type='checkbox'  value='Other'  id='choice_10_58_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_58_2' id='label_10_58_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_46\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_46\"><small><font color=\"red\">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.<\/font><\/small><\/div><fieldset id=\"field_10_56\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_56\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Counseling Medical Records Only:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_10_56'><div class='gchoice gchoice_10_56_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.1' type='checkbox'  value='Entire Medical Records (This includes sensitive information)'  id='choice_10_56_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_56_1' id='label_10_56_1' class='gform-field-label gform-field-label--type-inline'>Entire Medical Records (This includes sensitive information)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_10_56_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.2' type='checkbox'  value='Other'  id='choice_10_56_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_56_2' id='label_10_56_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_47\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_47\"><small><font color=\"red\">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.<\/font><\/small><\/div><div id=\"field_10_57\"  class=\"gfield gfield--type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_57\"><label class='gfield_label gform-field-label' for='input_10_57' >If &quot;Other&quot; is selected above then please include a description of specific information to be disclosed:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_57' id='input_10_57' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_10_15\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_15\"><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_10_16\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_16\"><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_10_43\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_43\"><legend class='gfield_label gform-field-label'  >Release Information to:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_43'>\n\t\t\t<div class='gchoice gchoice_10_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Self (Same as Patient Name)'  id='choice_10_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_43_0' id='label_10_43_0' class='gform-field-label gform-field-label--type-inline'>Self (Same as Patient Name)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='Other'  id='choice_10_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_43_1' id='label_10_43_1' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_24\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_24\"><legend class='gfield_label gform-field-label'  >I request that the records\/health information be sent by:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_24'>\n\t\t\t<div class='gchoice gchoice_10_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Secure Encrypted Email'  id='choice_10_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_24_0' id='label_10_24_0' class='gform-field-label gform-field-label--type-inline'>Secure Encrypted Email<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Fax'  id='choice_10_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_10_24_1' id='label_10_24_1' class='gform-field-label gform-field-label--type-inline'>Fax<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_44\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_44\"><label class='gfield_label gform-field-label' for='input_10_44' >Name or Organization<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_10_44' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_22\"  class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_22\"><label class='gfield_label gform-field-label' for='input_10_22' >Secure Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_22' id='input_10_22' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_10_45\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_45\"><label class='gfield_label gform-field-label' for='input_10_45' >Name or Organization<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_10_45' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_54\"  class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_54\"><label class='gfield_label gform-field-label' for='input_10_54' >Fax Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_54' id='input_10_54' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_39\"  class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_39\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_10_39' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_10_39_1_container' >\n                                        <input type='text' name='input_39.1' id='input_10_39_1' value=''    aria-required='true'    \/>\n                                        <label for='input_10_39_1' id='input_10_39_1_label' class='gform-field-label gform-field-label--type-sub '>Address 1<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_10_39_2_container' >\n                                        <input type='text' name='input_39.2' id='input_10_39_2' value=''     aria-required='false'   \/>\n                                        <label for='input_10_39_2' id='input_10_39_2_label' class='gform-field-label gform-field-label--type-sub '>Address 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_10_39_3_container' >\n                                    <input type='text' name='input_39.3' id='input_10_39_3' value=''    aria-required='true'    \/>\n                                    <label for='input_10_39_3' id='input_10_39_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_10_39_4_container' >\n                                        <select name='input_39.4' id='input_10_39_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_10_39_4' id='input_10_39_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_10_39_5_container' >\n                                    <input type='text' name='input_39.5' id='input_10_39_5' value=''    aria-required='true'    \/>\n                                    <label for='input_10_39_5' id='input_10_39_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_39.6' id='input_10_39_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_10_23\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_23\"><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_10_32\"  class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_32\"><br><small><strong>I understand that:<\/strong> 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.<\/small><\/br><\/div><fieldset id=\"field_10_48\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_48\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Electronic Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_10_48'><div class='gchoice gchoice_10_48_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.1' type='checkbox'  value='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\u2019s health records and information to Student Health Services of BU.'  id='choice_10_48_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_48_1' id='label_10_48_1' class='gform-field-label gform-field-label--type-inline'>I have carefully read and I understand this Authorization form. I have had any questions explained to my satisfaction. 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