This is a print-only form. You cannot complete this form on-line. We must have your signature. You may fax or mail it to the Medical Records Section.
Payment is made at time of request.
This authorization is void within 60 days from the date of signature. I further hereby certify that I understand the nature of this release. Please also note that the Student Health Service will not photocopy any material that was not originated in our facility. All rights reserved.