Student Health Services Valdosta State University Valdosta , GA 31698

NAME____________________ SSN ______________________ GENDER__________________ DOB______________________ TELEPHONE______________

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION PURSUANT TO HEALTH INSURANCE PORTABILITY AND ACCOUNTABILTIY ACT OF 1996 (HIPAA)

I authorize Student Health Services at Valdosta State University, Valdosta, GA, to use or disclose the above named individual's health information as described below.

The following information is to be disclosed:

_____Entire Record          _____Immunization Record

_____Lab Results          Please list test(s)/date(s)________________________________________

_____X-ray and imaging reports          Please list test(s)/date(s)_____________________________

_____Last visit          Please state date of service_________________________________________

_____Other          (Please specify date(s) of service or specific information) ___________________

______________________________________________________________________________

I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse. I do NOT authorize Student Health Services to disclose any of the following information:

*    AIDS/HIV                                                         *     Alcohol/Drug Abuse

*     Sexually Transmitted Diseases                    *     Behavioral/Mental Health

This information may be disclosed to and used by the following individual or organization:

Name/Organization______________________________________________________________

Address_______________________________________________________________________

City_______________________State__________________________Zip Code______________

Purpose of disclosure: *     At the request of the individual     *     Other_____________________

* I will pick up the copies myself (please allow 24 hours to process and please bring a Picture ID to pick up)
* Please mail the copies to the address listed above

THIS AUTHORIZATION DOES NOT EXTEND TO RECORDS MAINTAINED BY THE COUNSELING CENTER.

I understand that treatment, payment, enrollment in a health plan, or eligibility for benefits is NOT conditioned on my signing this Authorization. However, Student Health Services may condition the provision of health care for the purpose of disclosing to a third party protected health information specifically created for that third party, or for participating in research related treatment upon my agreement to use and disclose this information.

By signing below, I acknowledge that I have read and understand this document, that I have voluntarily given my authorization to Student Health Services to disclose my records, and that I may revoke this Authorization, except if this Authorization was obtained as a condition of obtaining insurance coverage, at any time by providing a written notice to Student Health Services to the attention of the Manager of Medical Records. The revocation shall be effective except to the extent that Student Health Services has already used or disclosed information in reliance on the Authorization. I understand that my information may be redisclosed by the authorized person/organization receiving the information, and at that point, the information attached hereto no longer be protected under the terms of this agreement. Please refer to Notice of Health Information Privacy Practices for more detailed information. Unless otherwised revoked, this authorization will expire on the following date, event, or condition__________________________________.

I understand that the University System Office of the Board of Regents of the University System of Georgia and Valdosta State University assumes no responsibility for the use or misuse by others of my health information disclosed under this authorization. I release the Board of Regents of the University System of Georgia and its agents and employees from all legal liability that may arise from this authorization.

Signature_____________________________________________ Date___________________

The above authorization is given on this patient's behalf because the patient is a minor or is unable to sign for the following reasons:_____________________________________________

______________________________________________________________________________

Signature_____________________________________________ Date___________________

                 Relative/Guardian/Personal Representative

Date copy given to patient__________Processed by_______________________Date_________

* Speech Clinic                                                                         Name_______________________

* Student Health Services                                                                 SSN________________________
* Athletic Department                                                                        Gender______________________
* Human Resources                                                                                     DOB________________________

* Other. Please Specify ___________________________       Telephone____________________

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION PURSUANT TO HEALTH INSURANCE PORTABILITY AND ACCOUNTABILTIY ACT OF 1996 (HIPAA)

I authorize _________________ Department of Valdosta State University, Valdosta, GA, to use or disclose the above named individual's health information as described below.

The following information is to be disclosed:

_____Entire Record          _____Immunization Record

_____Lab Results     Please list test(s)/date(s)________________________________________

_____X-ray and imaging reports     Please list test(s)/date(s)_____________________________

_____Last visit     Please state date of service_________________________________________

_____Other     (Please specify date(s) of service or specific information) ___________________

______________________________________________________________________________

I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse. I do NOT authorize the above referenced University Department to disclose any of the following information:

*     AIDS/HIV                                                        * Alcohol/Drug Abuse

*     Sexually Transmitted Diseases                    *      Behavioral/Mental Health

This information may be disclosed to and used by the following individual or organization:

Name/Organization______________________________________________________________

Address_______________________________________________________________________

City_______________________State__________________________Zip Code______________

Purpose of disclosure: *      At the request of the individual     *     Other_____________________

*       I will pick up the copies myself (please allow 24 hours to process and please bring a Picture ID to pick up)

*       Please mail the copies to the address listed above

THIS AUTHORIZATION DOES NOT EXTEND TO RECORDS MAINTAINED BY THE COUNSELING CENTER.

I understand that treatment, payment, enrollment in a health plan, or eligibility for benefits is NOT conditioned on my signing this Authorization. However, Valdosta State University may condition the provision of health care for the purpose of disclosing to a third party protected health information specifically created for that third party, or for participating in research related treatment upon my agreement to use and disclose this information.

By signing below, I acknowledge that I have read and understand this document, that I have voluntarily given my authorization to Valdosta State University to disclose my records, and that I may revoke this Authorization, except if this Authorization was obtained as a condition of obtaining insurance coverage, at any time by providing a written notice to Valdosta State University to the attention of the Manager of Medical Records. The revocation shall be effective except to the extent that Valdosta State University has already used or disclosed information in reliance on the Authorization. I understand that my information may be redisclosed by the authorized person/organization receiving the information, and at that point, the information attached hereto no longer be protected under the terms of this agreement. Please refer to Notice of Health Information Privacy Practices for more detailed information. Unless otherwised revoked, this authorization will expire on the following date, event, or condition__________________________________.

I understand that the University System Office of the Board of Regents of the University System of Georgia and Valdosta State University assumes no responsibility for the use or misuse by others of my health information disclosed under this authorization. I release the Board of Regents of the University System of Georgia and its agents and employees from all legal liability that may arise from this authorization.

Signature_____________________________________________ Date___________________

The above authorization is given on this patient's behalf because the patient is a minor or is unable to sign for the following reasons:_____________________________________________

______________________________________________________________________________

Signature_____________________________________________ Date___________________

           Relative/Guardian/Personal Representative

Date copy given to patient__________Processed by_______________________Date_________