Release of Medical Information

To release your medical information to someone other than yourself, please fill out the following form:

Permission for Release of Medical Information

**The Student Health Clinic will not disclose your medical information to anyone unless YOU give your written permission for us to do so.  This means we will not tell your roommates, your friends, the faculty, staff, or even family members about any of your appointments, phone calls to our nurses, or visits with our providers and staff unless we have received a signed copy of the release form accessed above.

After printing off, filling out, and signing the Release of Medical Information form, please scan it back in to your computer and fax or email it to us:

FAX: (501) 450-3370