MEDICAL RELEASE FORMCWU StudentDisability Services/Student Success
(Student Completes This Section)
I hereby authorize the above named health care provider to complete this form and disclose to Central Washington University and its authorized representatives the following information related to my health care: the diagnosis(es) of relevant conditions, treatment plan(s), my ability to perform in the educational setting, recommendations, history, reports and correspondence.
I understand that it may be necessary for the university representatives to share this information for purposes related to accommodation of a disability. I authorize the university to share this information among appropriate staff and authorized representatives to the extent necessary to determine whether accommodation is necessary and to administer the accommodation process. My health record may include information related to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), human immunodeficiency virus (HIV) behavioral or mental health services, and treatment for alcohol and drug abuse.
Once disclosed, the law does not always require the recipient to maintain the confidentiality of my health care information. I understand that I have the following rights: a) to inspect or receive a copy of my protected health information, b) to receive a copy of this authorization, and c) to refuse to authorize this action. I understand that information obtained under this release is a confidential medical record and is maintained separate from my student records. This authorization is valid for 90 days after the date of my signature below. However, I understand that I may revoke this consent, in writing, at any time except to the extent that action has already been taken based on the original authorization. I also understand that the above-named health care provider will not condition treatment or payment based on receipt of this signed authorization.
I hereby authorize my health care provider to discuss directly with a university representative any medical/mental health information relevant to my accommodation request. By authorizing this page, I acknowledge that I have read and agree to the terms described above. (Note to Student: If you do not provide authorization for your health care provider to discuss the medical/mental health information relevant to your accommodation request, processing of your accommodation request may be delayed.)
To send this form to your medical provider, fill in the providers Email address in the field below and click submit.