Consent to release medical information TO Weigel

Please fill-in the form below. All fields are required.

1) Student Demographics
 Input
Patient Name:
Patient Last Name:
Patient Middle:
Maiden Name (if applicable):
Date of Birth:
Banner ID: Open User Lookup
Phone Number:
Email:
2) Release information from
(Provider Info.)		  
Provider Name or Office
Street:
City:
State:
Zip Code:
Phone Number:
Fax Number:
RELEASE RECORDS TO:
Weigel Health Center
Buffalo State University
1300 Elmwood Ave.
Buffalo, NY 14222.
3) Medical Information to be sent
Please check all that apply
Copy of last annual GYN
Immunization Records
Physical Exam:
Pap Smear
GC and Chlamydia tests:
Copy of any abnormal tests:
Summary of treatment for:
Other (please specify):
Electronic Signature Disclaimer for Release of Medical Information
By electronically signing this authorization, I acknowledge and agree to the following:
1. Voluntary Authorization: I authorize the release of my medical information to the designated office as specified in this request.
2. Electronic Signature Validity: I understand that my electronic signature carries the same legal effect as a handwritten signature and confirms my intent to authorize the release of my medical information.
3. Scope of Information: I authorize the release of the specified medical records, which may include sensitive information.
By signing below, I confirm that I have read, understand, and agree to the terms of this authorization.
Electronic Signature:
Date: