Rebuilt HTML — PaddleOCR-VL (Baidu)
Semantic HTML reconstructed from the OCR item tree (headings, text, lists, tables, form fields). overlay · view JSON
Counseling T: (502) 597-6969 T: (502) 597-6970 F: (502) 597-6565
Student Health Services 400 East Main Street Frankfort, KY 40601
Consent to Release Confidential Health Care Information
- Patient
- Name-Last, First, MI DOB KSU Class
- Street Address
- City State ZIP Phone
- Release Information FROM: 3. Release Information TO:
- __ KSU Student Health Services __ KSU Student Health Services
- __ KSU Counseling __ KSU Counseling
- Treatment Provider (if applicable) Treatment Provider (if applicable)
- __ Other (complete box below): __ Other (complete box below):
- Name (i.e., Health Facility, Physician, etc.) Name (i.e., Health Facility, Physician, etc.)
- Street Address Street Address
- City State Zip City State Zip
- Telephone # Fax # Telephone # Fax #
- Information to be Released (Check All That Apply) — Attendance/Participation in Counseling — Psychotherapy notes — Result of evaluations — Clinical summary letter or email — Verbal clinical summary
- _Complete Copy of All Records
- — Attendance/Participation in Counseling
- _Immunizations
- Psychotherapy notes
- _Lab Results
- Result of evaluations
- _Progress Notes: all
- Clinical summary letter or email
- Or specified dates
- ___ Verbal clinical summary
- ___ Other (specify):
- I am a
- Check here if ONLY Records May Be Released (i.e. conversations, including those intended for clarification or follow-up, are not authorized)
- Purpose for Disclosure (check All That Apply)
_ Facilitate coordination of health care _ Academic Adjustment or Accommodations
— Other (specify): _____
Personal
I understand that I am giving my permission to the above named treatment provider or other named third party for disclosure of confidential health care information, including both records and discussions pertaining to those records, unless otherwise noted in Section 4 above. This consent is not a condition for treatment at the Kentucky State University Student Health Services or Counseling. I also understand that I have a right to revoke this consent, but that my revocation is not effective until delivered in writing to the person who is in possession of my records. A copy of this consent and a notation concerning the persons or third parties to who disclosure was made shall be included with my original records. The person who receives the records to which this consent pertains may be subject to re-disclosure by the recipient and no longer protected. I have the right to refuse to sign this authorization.