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If you would like Counseling and Human Development staff to disclose/share
your Protected Health Information with an outside source, please download and
complete this pdf document and
either mail or fax it ATTN: CHD (Counseling and Human Development). Our contact
information is on the form. Your signature is required.
There is a processing fee to cover the cost of photocopying and handling.
The fee is waived for copies to other health care providers.
Guidelines to help you complete this form:
Generally, students wish to release "information pertaining to my
treatment at CHD/Dick’s House" to an outside source, which may be another
office on campus (such as the Dean’s Office, Judicial Affairs, Residential
Life, Academic Skills Center Staff, etc.) or off campus (such as parents,
doctors/therapists, etc.).
The purposes of such requests vary, but some examples are: Continuity of
Care, Information Sharing, Notice that I attended my required drug/alcohol
assessment (if so, be sure to initial "I do" under statement #1),
Support for: Medical Withdrawal, Psychiatric Disability, Special housing needs,
COS Hearing, Academic Support Needs.
You will need to sign your name and date the form in addition to printing
your full name, graduation year and birth date. You can contact our office if
you have questions at 603-646-9442.
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