<p> 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</p><p>Date: ______</p><p>Patient’s Name (Print):______Maiden Name: ______Birth Date: ______Social Security #:______Phone#:______Student Id #:______Dates of Attendance: ______Program (if any) ______</p><p>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:______</p><p>Please only initial the information below that you would like released. Initials</p><p>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)______</p><p>Purpose for which disclosure is being made: (Please check one of the following)</p><p>( ) Attorney ( ) Insurance ( ) Doctor ( ) Personal ( ) Clinical</p><p>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.</p><p>Student Health Services requires a 72 hour minimum processing time for records. </p><p>Signature: ______Date:______(Patient, Guardian*, or Authorized representative*) *Please provide documents to prove authority to sign on behalf of the patient.</p><p>This authorization will expire 120 days from the date signed. Possible copying fee required</p><p>For office use only: Records sent______on (date) ______by______</p>