Illinois Authorization For Release of Confidential Health Information
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___________________________________________________________________________________________________________________________________________________________
Health Service
Northwestern University
633 Emerson Street
Evanston, Illinois 60208-4000
Phone 847-491-8100
Fax 847-491-8699

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION
Requests for Mental/Behavioral Health records MUST be made through Counseling and Psychological Services, please call 847-491-2151.

Patient Name (Please Print)

Date of Birth

Name as a student (if different than above)

______ ______ Student ID

E-mail

Year Entered NU

__

_______ Phone _

PLEASE RELEASE THE FOLLOWING HEALTH INFORMATION:
CHECK OFF EACH ITEM TO BE RELEASED. Requests for HIV/AIDS and/or Alcohol/Drug records require that you initial below.
Be as specific as possible:
X-Ray Report
______ Initial for release of Alcohol/Drug record
__X-Ray Film – Charge applies
______ Initial for release of HIV/AIDS record
TB Test Result
Immunizations – Specif