Release of Information

Authorization to Release/Obtain/Exchange Confidential Information

 

Instructions: In order for the Counseling Center to release, obtain, or exchange confidential information, this authorization must be completed according to these instructions.  All information must be clearly legible.  All information related to identification, location, and communication of those involved in the release of information must be provided.  This is necessary to ensure that the information is released only to those you intend.  For your protection, if this form is incomplete or is not legible, the Counseling Center will not release or request the release of any information.  (See the other side for assistance in completing this form and for signature verification requirements of authorizations received/sent by fax.) 

DISCLOSURE WITHOUT AUTHORIZATION IS PROHIBITED BY LAW (Texas Health and Safety Code, Sec. 611.00(4)4)

I, _______________________________	_______________________________________
Printed first and last name	Texas State Student ID#
______________________________________	_______________________________________
Date of Birth	Street Address/Residence Hall/Apt #
(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___	______________________________________
Telephone	City, State, Zip Code

AUTHORIZE the clinical or administrative staff at the Texas State University Counseling Center, LBJSC 5-4.1, 601 University Drive, San Marcos, TX  78666, (512) 245-2208

TO (Initial one only) ____Release to self  ____release to  ____OBTAIN FROM  ____exchange with

___________________________________	___________________________________
Printed name of person/agency	Street Address/ P.O. Box Number/Agency/Department
________________________________________ City, State, Zip Code	(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___ Telephone   (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___ Fax

(Initial all that apply)

_____Communication regarding a referral                                                     _____ Date(s) of attendance and type(s) of services received

_____Results of assessment(s) and recommendations                                _____ Progress in counseling

_____A letter for the purpose stated below (see back of this form)          _____ Copy of my counseling record

_____Other: (Specify) _____________________________________________________________________________________________

The purpose for releasing this information is:_____ For continuity of care _____ For academic purposes _____ At the request of the client

_____Other: (Specify) ______________________________________________________­_____________________________________

I understand that no disclosure of my records can be made without my written consent, unless otherwise provided by law, and that I may revoke this authorization in writing at any time, except to the extent that information has already been released.  This authorization permits the release of documentation of services provided by the Counseling Center.  I hereby release the above parties from any legal liability resulting from the authorized release of information.  This authorization expires

(Initial one only): 

_____One time, _____Sixty (60) days, _____six (6) months, OR _____one (1) year from the date below authorizing this release,

OR ___________________________________________________________________________________________________________

(Specify alternate expiration)

Requests For Release By Fax.  Information sent by fax may not be secure. Your privacy could be compromised.  With this in mind, if you choose to have confidential information sent by fax to us or from us, signify authorization by initialing here_____, and provide the fax number to be used: (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___.

 

______________________________________________________________________________________________________________

                       Signature of Client                                           Date of Birth                                              Date Authorized

The Counseling Center cannot guarantee confidentiality of information after it is released.

AUTHORIZATION OPTIONS

 

 

 

Release to Self:  To individual for use at their discretion.

 

Release to: Authorization is to release information only to the identified person

 

Obtain from:  Authorization is to obtain information from another source

 

Exchange with: Authorizes the two designated parties to share information.  This option provides the greatest flexibility for communication.

 

Letters released are commonly for these purposes: (The following are examples)

 

• To show (designated person) that I am or have been in counseling
• To send records to a new care provider (transfer of care) or consultant
• To document assessment and recommendations based on engaging in therapy
• Financial aid or academic appeal processes.

 

 

Authorizations Sent to or Received by the Counseling Center by Fax or Email

Authorizations received by fax or email for the Counseling Center to release or obtain information will be accepted if a signature verification can be made.  Acceptable sources that must accompany the fax or email request include: 1) This form signed in the presence of and notarized by a Notary Public; or 2) a copy of a valid driver’s license with photo and signature; or 3) a copy of another government issued document containing a photo and a signature, such as an identification card or a passport. 

 

 

 

 

 

 

 

 

 

The Counseling Center cannot guarantee confidentiality of information after it is released.