ࡱ> UWTO bjbjrKrK 4!e!e #####7778o76,+++++++$-0+#+##+:##++V5(@(=śRFu( +,06,( z1z1(z1#(r++6,z1 : ***Complete Form, Print, Sign and return to ATU Health & Wellness Center*** ARKANSAS TECH UNIVERSITY HEALTH & WELLNESS CENTER PERMISSION FOR RELEASE OF INFORMATION I, _______________________________ Tech ID# _________________________ (Print Name) Date of Birth__________________________ Phone _________________________________ Request that M6 Health & Wellness Center, or ________________________________________________________________________ (Name of Institution/Business) Release the following information from my health record: (Check all that apply) ___Lab results ___Immunization records ___Entire medical record __ TB Skin Test ___Care delivered on this specific date only _____/_____/_____ ___Care delivered for _______________________ only (specific illness/injury) ____All counseling records ___Counseling summary letter (diagnosis/treatment summary) This information is to be released to: Health & Wellness Center OR ________________________ M6 Name 1605 Coliseum Drive. ________________________ Doc Bryan Building Ste. 119 Address Russellville, AR 72801 ________________________ City/State/Zip Fax 479-967-6610 ________________________ Telephone Number ________________________ Fax Number I understand that I may revoke this authorization at any time by providing a written notice of revocation to  HYPERLINK "mailto:hwc@atu.edu" hwc@atu.edu. Such revocation will not affect any action taken in reliance on this authorization before receipt of my written revocation. The information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected by federal privacy regulations or other applicable state or federal laws. I release M6 and the offices of Health Services, Counseling Services, its officers, partners, agents, and employees from any and all liabilities, responsibilities, damages, and claims that may arise from the release of information pursuant to this authorization. ________________________________ ___________________ Signature Date     +/KLM    - 2 T U V  = S U X  8 žž̯ے̷۷юhv hE}h)7hSX5hv h)75CJaJh)75CJaJh)7h)75 h)7hSX h)7h)7 h)7hv h)75 hE}5 hv 5 hSX5hSX hI5hv hICJaJhW9h)7hI3LMf  U V   T U 8 gdSX$a$gdSXgdIgd)7$a$gd)7$a$gdI8 < R    , J o w  = H I UWswy̺䚒hlrjhlrUhv hv 5 h)75h)7h)70Jjh)7h)7U h)7h)7h)7hv 5CJaJ h<5hv hv 5CJaJhv hv 5CJaJ hv 5hv hE} hE}hE}hE}CJaJ.  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PP^P`o(--......k;<$yW}l UOW9XG C, e v \?L IXz_Dr-8wnhn:>f!3"%;%"4'6**=,"--(/;03)7$80999&9::<=Ia>%L?xAWD`D71E&#H\GHJHbI!1N ,PQQnQ RT&S,S3"T V!WUW`WSXzcX5Z$[H[p^4A`06a5Fd{Le9.f^huhjqj9kmklosCvzFv9wJx`ey{yl {A}E}2S-CQ#B..[}$VVT%y,YK>@VNJe]&u.wVlr^,[KKv j-My*6Q7[D9<'.<s7O1 Z@bjF!C5C$&4>[~xp B3Tg^d~X!}X*#jvyK9zi@>v5aI9|4D\-u@@UnknownG.[x Times New Roman5Symbol3. .Cx Arial5. .[`)TahomaC&,*{ @Calibri Light7.*{$ CalibriA$BCambria Math"hGGZJZJZ!243QHP ?I2!xxm" G***Complete Form, Print, Sign and return to Health & Wellness Center*** julie.hood Kristy Davis   Oh+'0H$0D \h    H***Complete Form, Print, Sign and return to Health & Wellness Center*** julie.hood Normal.dotmKristy Davis2Microsoft Office Word@F#@g@@JZGFVT$mN1 ?#   0.@Times New Roman--- L2 o+0 ***Complete Form, Print, Sign and return to        2 o0   2 o0 ATU   2 o0   42 o0 Health & Wellness Center***     2 o0   @Times New Roman---  2 |0   @Times New Roman--- /2 !0 ARKANSAS TECH UNIVERSITY       2 0    /2 0 HEALTH & WELLNESS CENTER      2 0    C2 %0 PERMISSION FOR RELEASE OF INFORMATION           2 O0     2 x0   ---  2 x0   ---  2 x0 I 2 ~0 , _ 52 0 ____________________________ 2 n0 __ 2 ~0    2 0   2 0 Tech  2 0 ID#   2 0   2 0 __ .2 0 _______________________  2 0   ---------  2 x0  0 2 0  ---  2 0    2 0 ( 2 0 Print Name     2 0 )  2 0   ---  2 x0   @Times New Roman--------------------- 2 !x 0 Date of Birth  --- 22 !0 __________________________ 2 !0    2 !0    2 !0  --- 2 !0 Phone ---  2 !0   =2 !!0 _________________________________  2 !0   ---  2 3x0    n2 FxB0 Request that M6 Health & Wellness Center, or          2 FR0     2 Xx0    w2 jxH0 ________________________________________________________________________ ------------  2 } 0  0  2 }P0 (--- 52 }U0 Name of Institution/Business      2 } 0 )---  2 }0     2 0   ------------ L2 x+0 Release the following information from my h        "2 0 ealth record: --- ,2  0 (Check all that apply) ---  2 0     2 x0   --------- 2 x0 ___--- 2  0 Lab results   2 0   2 0   82 0 ___Immunization records ___    +2 0 Entire medical record     2 ;0   "2 @0 __ TB Skin Test     2 0    2 x0 ___ 2  0 Care delive  :2 0 red on this specific date only    %2 0 _____/_____/_____  2 0    2 x0 ___ P2 .0 Care delivered for _______________________ onl   (2 0 y (specific illness  2 D0 /injury)  2 t0    2 0   ------------ 2 x0 ____--- ,2 0 All counseling records    2 0   b2 ":0 ___Counseling summary letter (diagnosis/treatment summary)         2 0     2 x0   --- D2 "x&0 This information is to be released to:      2 "r0   @Times New Roman---  2 0x0   --- /2 Ax0 Health & Wellness Center     2 A*0    2 A80  0  2 Ah0  0 2 A0 OR   2 A0    2 A0  0 /2 A0 ________________________  2 A0   --------- /2 Sx0 M6      2 S(0    2 S80  0  2 Sh0  0  2 S0  0  2 S0  0  2 S0  0 2 S(0  --- 2 S@0 Name  ---  2 S_0    )2 fx0 1605 Coliseum Drive.     2 f 0  .  2 f80  0  2 fh0  0  2 f0  0  2 f0  0 /2 f0 ________________________  2 f0   --------- 42 xx0 Doc Bryan Building Ste. 119      2 x90  /  2 xh0  0  2 x0  0  2 x0  0  2 x0  0 2 x(0  --- 2 x<0 Address   2 xi0   --- .2 x0 Russellville, AR 72801    2 0  #  2 80  0  2 h0  0  2 0  0  2 0  0 /2 0 ________________________  2 0   @"Arial--------- 2 x0 479  2 0 - 2 0 968  2 0 - 2 0 0329 ---  2 0  U---  2 (0    2 +0 City/State/Zip   2 x0    0''--- 2 x0 Fax 479   2 0 - 2 0 967  2 0 - 2 0 6610  2 0    2 0  0  2 80  0  2 h0  0  2 0  0  2 0  0 /2 0 ________________________  2 0   ---------  2 x0  0  2 0  0  2 0  0  2 0  0  2 80  0  2 h0  0  2 0  0  2 0  0 2  0  --- #2 $0 Telephone Number    2 0   ---  2 x0  0  2 0  0  2 0  0  2 0  0  2 80  0  2 h0  0  2 0  0  2 0  0 .2 0 _______________________  2 0 _  2 0   ---------  2 x0  0  2 0  0  2 0  0  2 0  0  2 80  0  2 h0  0  2 0  0  2 0  0  2 0  0 2 (0  --- 2 8 0 Fax Number    2 }0   ---  2 x0    2 xU0 I understand that I may revoke this authorization at any time by providing a written          /2 x0 notice of revocation to   c2   0 hwc@atu.edu  G2 `(0 . Such revocation will not affect any a     "2 \0 ction taken in @Times New Roman---c-- --- h2 *x>0 reliance on this authorization before receipt of my written re       42 *0 vocation. The information       2 <x 0 used or dis A2 <$0 closed pursuant to this authorizatio  2 <0 n m  2 <0 ay be su 2 < 0 bject to r (2 <#0 edisclosure by the    2 Nx0 rec S2 N00 ipient and no longer protected by federal privac  %2 N0 y regulations or    .2 N$0 other applicable state    )2 ax0 or federal laws. I   2 a0 release  2 a0   2 a0 Arkans  &2 aI0 as Tech University    2 a0   2 a 0 and the offi /2 a0 ces of Health Services,     X2 sx30 Counseling Services, its officers, partners, agents    =2 s!0 , and employees from any and all     @2 x#0 liabilities, responsibilities, dama    2 F 0 ges, and clai D2 &0 ms that may arise from the release of     2 x0 info =2 !0 rmation pursuant to this authoriz    2 ^0 ation.   2 0   ---  2 x0     2 x0    52 x0 ____________________________  2 X0 _ 2 `0 ___  2 x0    2 0  0 (2 0 ___________________  2 `0  (  2 0  0  2 0     2 x0 S  2  0 ignature   2 0    2 0  0  2 0  0  2 80  0  2 h0  0  2 0  0 2 0 Date   2 0   "Systemwc6--  00//..S$n@H0n ՜.+,D՜.+,t0 hp|  ATU H***Complete Form, Print, Sign and return to Health & Wellness Center*** Title 8@ _PID_HLINKSA`Cmmailto:hwc@atu.edu  !"#$%&()*+,-./0123456789:;<=>?@ABCDEFGHIJKMNOPQRSVRoot Entry FpvśX1Table1WordDocument4SummaryInformation('HDocumentSummaryInformation8LCompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q