ࡱ> .0-` bjbj *      $h z  ;;;   ;;;; `i3wA ;0;;;X  ; zy 1           APP State University Counseling Center Name______________________________________________ P.O. Box 2067 Date_______________________________________________ Thibodaux, LA 70310 Student or Employee ID#______________________________ 985.448.4080 Date of Birth________________________________________ Fax 985.448.4890 AUTHORIZATION FOR RELEASE OF INFORMATION I,___________________________________________________________hereby clients signature authorize_________________________________________________, of the APP Counseling Center _____ to OBTAIN from ______________________________________________________ Name of Person or Agency _____ to RELEASE to ______________________________________________________ _____ to MAKE TELEPHONE CONTACT with Address _____ to CORRESPOND with ______________________________________________________ by phone, email, via fax, etc. City, State, Zip Code ______________________________________________________ a copy of the following Telephone Number _____ Medical/Psychiatric Records _____ Psychotherapy evaluation/treatment records _____ Discharge summary and Diagnoses _____Verification of attendance _____ Other (please specify):_________________________________________________________________ for the purposes of _________________________________________________________________________ __________________________________________________________________________________________ All information I hereby authorize to be obtained from the agency will be held strictly confidential and cannot be released by the recipient without my written consent. It is further understood that information released is for professional purposes only and may not be provided in whole or part to any other agency, organization, or person other than stated above. I also understand and consent that this information may be sent via facsimile transmission. I understand that this authorization will remain in affect for: _____ ninety (90) days, unless I specify an earlier expiration date_____________________________ Date _____ one (1) year _____ the period necessary to complete all transactions on matters related to services provided to me ______________________ __________________________________________________________________ Date Signature of Client ______________________ __________________________________________________________________ Date Signature of Witness #$@Buv U b   Ż~~sfs~~Ż\Lh?h5OJQJ\aJhCJ OJQJhp2hp2CJOJQJhp25CJOJQJhqhq5CJOJQJh h CJOJQJhp2CJOJQJh 5CJOJQJhqhCJOJQJh CJOJQJhCJOJQJhCJOJQJh5CJOJQJ\h 5CJOJQJ\hq5CJOJQJ\$vV   X   \ { Z   < `gdq   %  # [ s y  o |jٌ}qeqYh?h6OJQJh?h?6@CJh?h6@CJh?h_ CJOJQJaJhCJOJQJaJh?CJOJQJaJh,MCJOJQJaJh0i!CJOJQJaJ h?h@CJOJQJaJh CJOJQJaJh_ CJOJQJaJh FCJOJQJaJh?hCJOJQJaJ< = n o vw@Pcd%BC^jh?hCJOJQJaJ h?h@CJOJQJaJ h?h@CJOJQJaJ(/ =!"#@$@% 8@8 Normal_HmH sH tH @@@ Heading 1$@& CJOJQJL@L Heading 2$$@&a$5CJOJQJ\F@F Heading 3$@&5CJOJQJ\DAD Default Paragraph FontViV  Table Normal :V 44 la (k(No List :B@: Body Text CJOJQJHH I Balloon TextCJOJQJ^JaJ  $vVX\{Z<=novw@ P c d % B C (000000000000000000000000000000000000000000000000000000 j <   MM?M4>M=MCM C $$/:vv      .9@@~     =*urn:schemas-microsoft-com:office:smarttags PlaceName=*urn:schemas-microsoft-com:office:smarttags PlaceType>*urn:schemas-microsoft-com:office:smarttags PostalCode: *urn:schemas-microsoft-com:office:smarttagsStreet9*urn:schemas-microsoft-com:office:smarttagsState8 *urn:schemas-microsoft-com:office:smarttagsCity; *urn:schemas-microsoft-com:office:smarttagsaddress9*urn:schemas-microsoft-com:office:smarttagsplace }    []V Y j m 33333333333333CC  b[y  I _ ? 0i!p2=idMIq,M F5 @  @UnknownGz Times New Roman5Symbol3& z ArialQ& Franklin Gothic DemiQ& Franklin Gothic Book5& zaTahoma"hӱӱ&# # 124d 2QHX(?idM2University of West FloridaPatriciaNSUserOh+'0  ( H T ` lxUniversity of West Florida PatriciaNormalNSUser2Microsoft Office Word@F#@j-Xe@!&wA@!&wA# ՜.+,D՜.+,d  hp   The University of West Florida  University of West Florida TitleD@ 8_AdHocReviewCycleID_EmailSubject _AuthorEmail_AuthorEmailDisplayName_ReviewingToolsShownOnceyP$electronic release of informationsbrewer@uwf.eduSandy Brewer  !"#$&'()*+,/Root Entry F 703wA11TableWordDocument* SummaryInformation(DocumentSummaryInformation8%CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q