[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283973-105":3,"doc-detail-283973-en":81,"detail-sidebar-cat-1-en-105":97},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","authorization-for-release-of-information-medical-records","Authorization for Release of Information Medical Records","","Authorization for Release of Information form enables a student to grant specific health providers and university offices permission to exchange and share medical information considered medically necessary. It covers release of medical records, appointment history, diagnostic reports, diagnosis, prognosis, and treatment plans, including related data. The form includes general consent terms, duration and cancellation/revocation conditions, plus special authorization for drug/alcohol treatment and mental health information, with signature, witness/parent, and validity period fields.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/authorization-for-release-of-information-medical-records/283973/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/authorization-for-release-of-information-medical-records/283973.png","ImageObject",442,249,{"name":42,"@type":43},"Grenda","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-30","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",12,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Who can receive and exchange my medical information under this authorization?","Question",{"text":63,"@type":64},"The form names specific medical facilities and university offices, and authorizes them to exchange information and release medical records and related data for the stated purpose.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"How long does this authorization remain valid?",{"text":68,"@type":64},"The consent remains in effect for one year from the date the student signs the authorization, with validity beginning and expiration fields provided.",{"name":70,"@type":61,"acceptedAnswer":71},"Can I cancel or revoke this authorization, and what limits apply?",{"text":72,"@type":64},"The student may cancel at any time except to the extent action has already been taken in reliance on the authorization, and may revoke by submitting a written request.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},283973,1790191935,{"code":4,"msg":82,"data":83},"success",{"doc_id":79,"user_id":84,"nickname":42,"user_avatar":85,"doc_module":22,"category_id":86,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":87,"file_id":88,"file_url":89,"file_type":90,"file_size":91,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":92,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":93,"faqs":94,"seo_title":95,"seo_description":12,"update_tm":96,"read_time":4},7971474921005,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0",17,"Health Center  \nDivision of Student Affairs Student Health Center Slippery Rock, PA 16057 724-738-2052 phone  \n724-738-2078 fax 724-738-4505 TDD  \n[www.sru.edu/offices/student-health-services](www.sru.edu/offices/student-health-services)  \nAuthorization for Release of Information  \nI,   DOB  (Student Name)  \n   Cell Phone  (Student Address)  \nHome Phone    \nauthorize  Butler Health System  Center for Community Resources  Clarion Psychiatric Center  \n Grove City Medical Center  SRU Counseling Center (x4532) fax  SRU Office of Disability Services (x4399) fax  SRU Director, Student Support  \nFAX  \n(Name of Physician, Practice, Facility)  \n(Address)  \nand: FAX  \n(Name of Physician, Practice, Facility)  \n(Address)  \nto exchange information as deemed medically necessary regarding my illness/injury:  \n  date of service:   , and to release to each other copies of my medical records, appointment history, diagnostic reports, diagnosis, prognosis, treatment plan and/or any other related data.  \nGeneral Authorization  \nI understand also that I may cancel this authorization at any time except to the extent that action has been taken in reliance thereon. This consent will remain in effect for one year from the date I signed this Authorization in order to accomplish its purposes. I understand that I may revoke this consent at any time by submitting a written request.  \nSpecial Authorization  \nI understand that my medical records may contain drug/alcohol treatment and/or mental health information and I give special authorization to the health care provider/ facility to release this information in my records to the person, physician, facility named above for the stated purpose. I understand that I may revoke this consent at any time by submitting a written request.  \nStudent Signature (If Student is less than eighteen years of age at the time of request, parental consent is also required.)  \nWitness (or Parent if Student is under 18 years of age)  \nDate  \nStudent Signature (If Student is less than eighteen years of age at the time of request, parental consent is also required.)  \nWitness (or Parent if Student is under 18 years of age)  \nDate  \nValid beginning / /  \nExpiration /  \nIMPORTANT INFORMATION ABOUT THESE RECORDS: The records and information that have been disclosed to you are records whose confidentiality is protected by State and Federal statute. Federal regulations limit your right to make any further disclosure of this information without prior written consent of the person to whom it pertains.","cbCaikuMykVMqarW","https://ap.wps.com/l/cbCaikuMykVMqarW","pdf",61661,"English","# Authorization for Release of Information\n## General Authorization\n## Special Authorization\n## Signatures and Validity","[{\"question\":\"Who can receive and exchange my medical information under this authorization?\",\"answer\":\"The form names specific medical facilities and university offices, and authorizes them to exchange information and release medical records and related data for the stated purpose.\"},{\"question\":\"How long does this authorization remain valid?\",\"answer\":\"The consent remains in effect for one year from the date the student signs the authorization, with validity beginning and expiration fields provided.\"},{\"question\":\"Can I cancel or revoke this authorization, and what limits apply?\",\"answer\":\"The student may cancel at any time except to the extent action has already been taken in reliance on the authorization, and may revoke by submitting a written request.\"}]","Authorization for Release of Information Medical Records | PDF",1789623611,{"code":4,"msg":82,"data":98},[99,104,108,113,118,123,126,131,136],{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},11,"Presentations",90,"presentations",{"id":55,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},"Resumes",80,"resumes",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":110,"show_sort_weight":111,"slug":112},14,"Invoices",70,"invoices",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},15,"Posters",60,"posters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},16,"Social Media",50,"social-media",{"id":86,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":124,"slug":125},40,"forms",{"id":127,"doc_module":22,"doc_module_name":25,"category_name":128,"show_sort_weight":129,"slug":130},18,"Letters",30,"letters",{"id":132,"doc_module":22,"doc_module_name":25,"category_name":133,"show_sort_weight":134,"slug":135},21,"Paper Templates",5,"papers-templates",{"id":137,"doc_module":22,"doc_module_name":25,"category_name":138,"show_sort_weight":4,"slug":139},158,"General","general-158"]