Patient Authorization for Use And/Or Disclosure of Protected Health Information

Patient Authorization for Use and/or Disclosure of Protected Health & Therapeutic Counseling Information North Idaho College, Student Health & Therapeutic Counseling Services, 1000 West Garden Avenue, Coeur d’Alene, Idaho 83814 Telephone Number: 208.769-7818 Fax Number: 208.625-2337

Date: ______

Patient’s Name (Print):______Maiden Name: ______Birth Date: ______Social Security #:______Phone#:______Student Id #:______Dates of Attendance: ______Program (if any) ______

I authorize ______to release my records to______Agency Agency and/or self I agree that this document will serve as a two-way release □ Yes □ No Agency Name: ______Address: ______City: ______State: ______Zip Code: ______Telephone Number:______Fax Number:______

Please only initial the information below that you would like released. Initials

1. General Health Records (not to include mental health or HIV/STD results)……………………………………………. _____ 2. Mental Health Records (must schedule an appointment with a Nurse Practitioner or Therapeutic Counselor to release to self) ………… _____ 3. Laboratory Results only……………………………………………………………………………………………… _____ 4. PAP Smear test Results……………………….………………………………………….…………….………… _____ 5. Immunization Records…………………………………………………………………………….………………. _____ 6. HIV or STD Results………………………………………………………………………………………..………. _____ 7. Other (please specify)______

Purpose for which disclosure is being made: (Please check one of the following)

( ) Attorney ( ) Insurance ( ) Doctor ( ) Personal ( ) Clinical

I understand that this authorization is voluntary and that the above information will not be released by North Idaho College, Student Health Services to any other person and/or organization unless I so authorize. I understand that the information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations. I understand that my healthcare and the payment of my healthcare will not be affected by my signing this form. I have the right to revoke this authorization in writing, but if I do it will not have an effect on any actions taken by Student Health Services before the revocation was received.

Student Health Services requires a 72 hour minimum processing time for records.

Signature: ______Date:______(Patient, Guardian*, or Authorized representative*) *Please provide documents to prove authority to sign on behalf of the patient.

This authorization will expire 120 days from the date signed. Possible copying fee required

For office use only: Records sent______on (date) ______by______