Release of Information Form

Release of Information completion instructions

ROI Form

Complete the following on the Release of Information Form:


1. Include name, current address, date of birth and current phone number.

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

3. Indicate information that is being requested including time period if appropriate. Special permission is required to release mental health, HIV, alcohol or drug and developmental disabilities records. Please check these areas if appropriate.

4. Indicate why you are requesting records.

5. Indicate specific time frame if appropriate.

6. Read statement.

7. Sign and date.

8. Fax or mail or drop form off at Student Health Services.

Release of Information outside of a health care clinic must be confirmed with a direct phone contact to you to verify information.