Patient Name:

Birth Date: Social Security Number:

I hereby request and authorize RowanSOM Department of to disclose to:

Name: (person to whom disclosure is made)

Address:

my medical records to the following extent:

(treatment date, RowanSOM health care unit in which treatment was provided, type of records to be excluded, if any) for (purpose of disclosure)

I understand that this authorization includes permission to release information related to the history, diagnosis and/or treatment of any psychiatric problems, mental illness, drug abuse, alcoholism, sexually transmitted or communicable disease, AIDS, or test for infections with human immunodeficiency virus (HIV), that my signing this document authorizes the Rowan University to release that information. I acknowledge and am aware that New Jersey has a statutory privilege accorded to confidential communications between a patient and a licensed physician or psychologist and that my signing this form waives this privilege.

 A check here indicated that I believe my medical records may contain DNA test results or other genetic information. Such information is specially protected by New Jersey law, and I will be contacted for separate, specific consent prior to release of this information.

I understand the nature of the authorization and that this authorization can be revoked at any time by the person giving authorization, with a written and dated notice, except to the extent that disclosure made in good faith has already been made prior to receipt of the revocation.

I understand that this authorization is specific for release only to the above party and expires (90) days following the date of signature.

 A check here indicated that I, the undersigned, understand that I assume full responsibility for the protection of this patient information provided via electronic file/CD under HIPAA laws.

Identify method of copy:  Paper  Electronic/CD (Must check above box also)

Rowan University will not make decisions concerning treatment, payment, enrollment or eligibility for benefits based on signing, refusing to sign or revoking this authorization.

I understand that I can be charged for obtaining copies of my records according to the fee schedule established in the New Jersey Administrative Code.

I understand if this authorization is for marketing purposes that Rowan may receive direct or indirect compensation.

Printed Name of Patient or Guardian: Signature of Patient or Guardian: Date: