Release of Information for the Student Health Center

Authorization to Exchange Confidential Information Between the

Counseling Center and Student Health Center

Instructions: In order for the Counseling Center and Student Health Center to 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 any information. 

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

AUTHORIZE my therapist, ____________________________, and/or the administrative or clinical staff at the Texas State University Counseling Center, LBJSC 5-4.1, 601 University Drive, San Marcos, TX  78666, (512) 245-2208 to exchange with the:

Student Health Center  Texas State University, 298 Student Center Drive, San Marcos, TX 78666 Phone (512) 245-2161

(Initial)     _____Relevant portions of the clinical/medical record                       

The purpose for releasing this information is for collaboration and continuity of care.

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.

____________________________________________________________________________________________________

                Signature of Client                               Date of Birth                                 Date Authorized