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CASSIUS COLLEGE STUDENT HEALTH CENTER 2001 Main Street, Buffalo, NY 14208 Phone: (716) 8882610 Fax: (716) 8883217 AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION Name Date of Birth Address: City

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How to fill out disclosure of health info

01

Step 1: Obtain a disclosure of health information form

02

Step 2: Read the instructions on the form carefully

03

Step 3: Provide your personal information, including your name, date of birth, and contact details

04

Step 4: Specify the purpose of the disclosure and the recipient of the information

05

Step 5: Indicate the dates or time period for which the disclosure is authorized

06

Step 6: Sign and date the form to acknowledge your consent for the disclosure

07

Step 7: Review the completed form and make sure all the information is accurate

08

Step 8: Submit the form to the appropriate party as per the instructions provided

Who needs disclosure of health info?

01

Patients who want to authorize the release of their health information to a specific individual or organization

02

Individuals participating in clinical research or studies who need to provide their medical history or related information

03

Insurance companies or healthcare providers who require access to a patient's health information for processing claims or providing treatment

04

Employers or government agencies conducting background checks or medical evaluations as part of their screening process

05

Legal entities involved in lawsuits or legal proceedings that require access to relevant health information

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