This form, when completed and signed by you, authorizes
Counseling and Psychological Services (CAPS) to release protected information from your clinical record to the person/agency you designate.
I, _______________________, authorize ________________________and/or his or her clinical supervisor at CAPS and/or the
Director of CAPS and/or the administrative staff at CAPS (cross out if not applicable) to release to and/or receive from: ___________________________________________
(individual(s) to whom information is being released)
The following information:
( ) Diagnoses
( ) Adherence to treatment recommendations
( ) Prognosis ( ) Ability to function in class work
( ) Results of testing and recommendations
( ) Psychological suitability for continuing in academic program
( ) Results of urine drug screens and other biological markers related to substance use
( ) Recommendations regarding medical leave of absence
( ) Attendance at therapy
( ) Treatment recommendations
( ) Lab results
( ) Letter summarizing my care
( ) Ability to function in clinics
( ) Other _______________________________________________________
I am requesting the release of this information for the following reasons:
( ) At the request of the individual (all that is required if you do not desire to state a specific purpose)
( ) At the request of the program
( ) Other ________________________________________________________
This authorization shall remain in effect until (fill in expiration date): ________________
I understand I have the right to revoke this authorization in writing at any time by sending such written notification to the CAPS office. However, my revocation will not be effective to the extent that CAPS has already taken action in reliance on the authorization.
I understand that CAPS generally may not make services conditional upon my signing an authorization unless the services are provided to me for the purpose of creating health information for a third party. (For example, if I am required by my Dean or Program Director to receive psychological evaluation or treatment.)
I understand that information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient of my information and no longer protected by the HIPAA Privacy Rule.
Signature of Patient
(If the authorization is signed by a personal representation of the patient, a description of such representative's authority to act for the patient must be provided.)
Fax to (843) 792-2535
For questions please call (843) 792-4930.