among NCSU covered health care components
CONSENT FOR RELEASE
OF HEALTH INFORMATION
Student Name: __________________________________________________________________________
First
Middle Initial
Last
Student ID#__________________
I grant consent to NC State University Student Health Services, the NC State Counseling Center, and the NC State University Department of Athletics Office of Sports Medicine to disclose to each other and their respective professional staff members all of my protected health information (except for psychotherapy information) for coordination of my health care at NC State University and I authorize each unit and their professional staff members to use such information for the purpose of such coordination in order to provide me with the best possible health care while I am a student at NC State University. This information also may be used and further disclosed by each unit for purposes of my treatment, to obtain payment for services rendered to me in connection with each unit’s health care program and for each unit’s health care operations activities.
This consent expires for each of the identified units when I cease to be a student at NC State University. This consent expires for the sharing of information with or by the Office of Sports Medicine when I cease to be a student-athlete at NC State University.
___________________________ ________________________________
Signature of Student Date
___________________________ ________________________________
Signature of parent/guardian Date
If the student is under the age of 18)