Administrative Office: 3301 College Ave., SAB 3rd Floor,
Davie, FL 33314
Fax: (954) 424-6915

AUTHORIZATION FOR RELEASE/REQUEST OF INFORMATION

I, DOB:
Name of Student (PLEASE PRINT)InitialsStudent ID #
hereby give my permission to Henderson Student Counseling Services or to the entity listed below to release information contained in my medical record. I understand that my medical record may contain information concerning my psychiatric, psychological, drug or alcohol abuse, sexual abuse treatment, HIV/Acquired Immune Deficiency Syndrome (AIDS) and/or related conditions, and that under Florida law these records are classified as privileged and confidential and cannot be released to me or those designated by me or my legal guardian without an expressed and informed consent. In addition, I understand that those records will not be released to entities other than those designated by myself or my personal representative or otherwise provided in Florida or federal law.

This information will be released/requested upon request to the following:
To/From:
Name and Address of Person(s), Agencies, Organization to which information is to be released/requested.

Purpose of this release/request:
I authorize release/request of information covering treatment dates of:
The type of information to be disclosed/requested is as follows:

To Be ReleasedTo Be Requested
          Treatment Plans          Treatment Plans
          Progress Reports          Progress Reports
          Health/Medical Records          Health/Medical Records
          Education Reports          Education Reports
          Discharge Summaries          Discharge Summaries
          Psychological/Psychiatric Evaluations          Psychological/Psychiatric Evaluations
          Social/Developmental History           Social/Developmental History
          Verbal Communication          Verbal Communication
          Other           Other
   I understand that I have the right to withdraw my authorization at any time except to the extent that action has already been taken pursuant to the authorization. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to Henderson Student Counseling Services.
   I understand that authorizing the disclosure of this health information is voluntary, I can refuse to sign, and Henderson Student Counseling Services will not base my treatment, payment or eligibility for benefits on whether or not I provide authorization for the requested use or disclosure. I understand that the recipient may be prohibited from disclosing substance abuse information. I understand that I may inspect or copy the information to be disclosed, as provided in CFR164.524 (with reasonable charge).
   I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient of the information and is no longer protected by federal confidentiality laws or Henderson Student Counseling Services.
   I understand that Henderson Student Counseling Services will release only the minimum amount of information necessary to fulfill a request.


Release: Request:

Student SignatureDateStudent SignatureDate

WitnessDateWitnessDate