===== PAGE 1 ===== 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 ### 1. Patient

Name-Last, First, MI		DOB	KSU Class
Street Address
City	State	ZIP	Phone
2. 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 #

4. 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

_Immunizations

_Lab Results

_Progress Notes: all

Or specified dates

___ 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) 5. Purpose for Disclosure (check All That Apply) _ Facilitate coordination of health care _ Academic Adjustment or Accommodations Personal — Other (specify): _____ 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.