Kentucky Authorization for Release of Medical Information Form
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EASTERN KENTUCKY UNIVERSITY
Serving Kentuckians Since 1906

DIVISION OF STUDENT AFFAIRS
Student Health Services
John D. Rowlett Building Rm. 103
521 Lancaster Avenue
Richmond, Kentucky 40475-3102
(859) 622-1761
FAX: (859) 622-1767

Authorization for Release of Medical Information

By my signature below, I ______________________________________, hereby authorize
(Name and DOB)

__________________________________ to release to ___________________________________ all medical
(Name of Health care facility)

(Name of Health care facility)

records, including records of office visits and consultations, results of labs, x-rays, and other diagnostic tests, for
the period from _________________ to __________________.
*Without your specific approval, we cannot release records related to Sexually Transmitted Diseases (STD),
Alcohol/Substance Abuse, Mental Health, and HIV/AIDS. Therefore, if you want these records included in the
release, please initial next to the appropriate area(s) below.
_____