• P.O. Box 755580, 1007 N. Chandalar Drive | Fairbanks, AK 99775-5580 | PH: 907-474-7043, FX: 888-837-2146| www.uaf.edu/chc

  • UAF Student Health and Counseling Center Authorization to Release Protected Health Information to UAF Athletics 

  • Date of request*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Student date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • I HEREBY AUTHORIZE THE DISCLOSURE AND USE OF MY HEALTH INFORMATION BETWEEN:

  • UAF Student Health and Counseling Center (UAF SHCC)

    1007 N. Chandalar Drive, PO Box 755580 Fairbanks, AK 99775

    Phone:  (907)474-7043; (Fax): (888)837-2146

  • AND

  • UAF Athletics Department

    1890 Tanana Loop Room 209 Fairbanks, Alaska 99775-7440

    Phone:  (907)474-2435

  • I HEREBY AUTHORIZE INFORMATION TO BE SHARED:
  • Type of records/information to be released:

  • What is the purpose of this disclosure?*

  • Expiration of Authorization:  This authorization will expire in one year

  • Re-disclosure: I understand that when the information is disclosed pursuant to this Authorization to someone who is not required to comply with the federal or state privacy protection requirements, it may be subject to re-disclosure by the recipient and may no longer be protected.

    Revocation: I understand that I may revoke this Authorization at any time by writing to the address above.  A request to revoke my authorization will not apply to the extent that SHCC has taken action in reliance upon this authorization. 

    Conditioning of Eligibility:  SHCC will not condition treatment, payment, and enrollment or benefit eligibility on my signing this document.

    If you are under age 18, your legal parent/guardian must sign this form. 

  • Please indicate the choice below that describes your role in signing this form.*
  • Date of Signature*
     - -
    2 digit month, 2 digit day, 4 digit year

  • The UAF Student Health and Counseling Center reserves the right to authenticate the patient's signature/guardian's signature on forms received by fax or mail prior to the release of the requested information.

  • UAF is an affirmative action/equal opportunity employer, educational institution and provider  and prohibits illegal discrimination against any individual: www.alaska.edu/nondiscrimination/.

  • Should be Empty: