Release of Information

Release of Information completion instructions

This form needs to be completed prior to University Counseling Services releasing any of your mental health records or having contact with your other providers:

Release of Information

* Please be advised that while mental health information is protected under state law, we urge caution and thoughtfulness when releasing information to another party.  Allowing for sharing of information about your care can be helpful to you and your providers, but please be aware that we can not protect you from re-release of your personal information once the record has left our system.

 

Complete the following on the Release of Information Form:

1. Include your name and date of birth.

2. Include name, address, phone, and fax number where information is being sent to or being requested from.

3. Indicate the information that is being requested in the first set of check boxes, including time period if appropriate.  Please be specific as to what information you would like released.

4. Indicate why you are requesting records in the Purpose or Need for Disclosure section.

5. Sign, date, and also obtain a witness signature on the bottom of the form.

6. Fax, mail, or drop form off at University Counseling Services.

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