HIPAA Consent Form

"*" indicates required fields

First Name*

Middle Initial*

Last Name*

Phone Number*

Email Address*

Date of Birth*

Student Health Services reserves the right to release health information based upon a decision by your medical provider here for medical emergency situations and in general for continuity of care. We will use your health information as needed to maintain our internal operations. We will release your information to anyone else that you may elect in writing to receive it.

Other than the above mentioned release, your personal healthcare information will NOT be released to others, including your parent(s), unless listed below.

Indicated by entering below, I give permission to provide information to the following:

Parent/Legal Guardian FULL NAME*

Parent/Legal Guardian Phone Number*

(FOR ATHLETES ONLY) By checking this box, I give permission to release my healthcare information to our SAU Athletic Training Staff and/or Program Director

Yes, I give my permission

No, I do not give my permission

Others: FULL NAME

Others Phone Number

Electronic Signature, Please Initial to Verify

Today's Date

HIPAA Consent Form

Other than the above mentioned release, your personal healthcare information will NOT be released to others, including your parent(s), unless listed below.

Indicated by entering below, I give permission to provide information to the following:

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