Release Form

Release Form

Release of records and medical information from Boe House
  • Name
  • Name
  • This Authorization expires one year after the date signed unless otherwise specified. I understand that I may revoke this Authorization at any time with written notification; the revocation will not have any effect on the information released prior to notification of revocation. This information may not be further released without specific consent of the above-named client. St. Olaf College Counseling Center will not refuse or restrict treatment if I choose not to sign this Authorization. A photocopy/fax/scanned image of this Authorization will be treated in the same manner as an original. Further, I realize that St. Olaf College Counseling Center cannot prevent the redisclosure of records released as a result of this request and that the records may not be subject to privacy rule protections; therefore St. Olaf College Counseling Center is released from any and all liability resulting from redisclosure.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY