CONSENT TO RELEASE CONFIDENTIAL INFORMATION

Name :	SSN: xxx-xx- DOB:

Address:

I, , give my consent to:

to obtain information from/disclose information to:

Susan L. Mangold, Student Services Coordinator

Robert T. Watrous, Associate VP & Dean

Student Services & Campus Life

Kutztown University

Kutztown, PA 19530

This information may be disclosed only for the following purpose(s):

Coordination of services.

The information to be disclosed is:

Psychological Test Results	Summary of Psychotherapy Contacts

Medical Records	Discharge summary with after-care plan/treatment recommendations

I understand that the information in various sections/portions of my records may include information related to sexual assault, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It also may include information about behavioral or mental health services, and treatment for alcohol and drug abuse.

I understand that I have no obligation to disclose any information from my confidential records. I further understand that I may revoke this consent at any time (except to the extent that action has been taken in reliance thereon) by written notification.

All information released will be handled confidentially. Federal regulation prohibits any further disclosure of this information without the specific written consent of the person to whom it pertains or that which is otherwise permitted by such regulations.

I understand that my authorization shall remain in effect for a period of one hundred twenty (120) days from the date of my signature. I permit a copy of this authorization to be used in lieu of the original.

I have had this form read and explained to me, and I understand its contents.

Signature of Client __________________________________	Date ______________________

Signature of Witness ________________________________	Date ______________________

revised 10/10