Student Health

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

Full Name (include any former names): _________________________________________________
Date of Birth: _________________________ SSN: _______ -_____ - ________
Phone: ___________________________ College: _____________________________
Dates of enrollment: ________________________________________________________________

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: __________________________________________________________________________

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.

______________________ _______   ___________________________ _____________
Signature                        Date        Witness Signature                     Date
____________________ _________________ _____________________ ____________
Legal Guardian/             Relationship to Student    Witness Signature      Date
Representative

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

Code Student Health