MUSC-STUDENT HEALTH SERVICES 30-A Bee Street – PO Box 250980 Charleston, South Carolina 29425 Phone (843) 792-3664 Fax (843) 792-2318 AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION |
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| Full Name (include any former names): _________________________________Date of Birth: ____________ SSN: ____ -___ - _____ Phone: ____________ College: ___________Dates of enrollment: ______________ |
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I authorize MUSC Student Health Services to (check one) disclose/release or to receive information on my behalf. The type of information to be disclosed is as follows: For dates of service: ________________________________ Immunization Record/Immune Titers Lab Results Office Visit/Progress Notes Consultation Reports Radiology Reports Entire Record Other_________________________________________ I understand this information may include reference to psychiatric/psychological care, drug abuse, alcohol abuse, sexual assault, and/or results of tests for all infectious diseases including HIV/AIDS. I authorize the disclosure of this information via (after I have paid Student Health Services any applicable fees): in person with proper picture ID mail fax other ___________________________________ The information is to be disclosed to: Self Individual/Organization:___________________________ Street Address: _____________________________________ City: _________________________ State: ______ Zip Code ______________ Phone Number: _________________________ Fax: __________________________ The purpose of the disclosure is: _________________________________________________________ |
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I understand that I have a right to cancel/revoke this authorization at any time. I understand that if I cancel/revoke this authorization I must do so in writing and present my written cancellation/revocation to Student Health Services. I understand that the cancellation/revocation will not apply to information which has already been released in response to this authorization as stated in the Notice of Privacy Practice. Unless otherwise canceled/revoked, this authorization will expire/end 90 days from this date. *I understand that a reasonable cost-based fee (fee schedule available at Student Health Services) for copies of protected health information and postage fees will be charged in accordance to SC law (SC 44- 115-80). Fees must be paid to Student Health Services in advance before any records will be released. MUSC Student Health Services aims to complete requests within two (2) business days; however if there is a delay, please understand that HIPAA allows thirty to sixty days to respond to an individual’s request for a copy of their medical records. I understand that authorizing the disclosure of protected health information is voluntary. I can refuse to sign this authorization. I do not need to sign this form to receive treatment. I understand I may review and/or copy the information to be disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the possibility of unauthorized disclosure by the person/organization receiving the information. If I have questions about the disclosure or use of my protected health information, I may contact the MUSC University Privacy Officer. I understand I will be given a copy of this authorization. I understand that if this information is requested in person I will be asked to provide picture identification (e.g. driver's license). A copy of my identification will be made and attached to this authorization.
To contact Student Health Service in writing, the address is: 30-A Bee Street / PO Box 250980 / Attention: Release of Information / Charleston, South Carolina 29425; the phone number is (843) 792-3664. jfr 3/30/05 |