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  1. Home
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  4. Health and Wellness Center
  5. Confidentiality and Privacy

Consent to Release Information

A copy of your confidential medical records can be provided to your insurance, or sent to an employer, another university, or continuing care provider after you sign a release of information form, available from the Health and Wellness Center. A copy of your medical records will be provided to you within five business days from the receipt of the release of information. You may pick a copy of the Consent to Release Information form at the Health and Wellness Center.

Please note a valid release must contain the following nine elements. We will not release records if you submit an incomplete form.

If you need assistance completing the form, please contact our office at 814-949-5540.

Content for a valid authorization includes:

  1. The name of the person or entity authorized to make the request (usually the patient)
  2. The complete name of the person or entity to receive the protected health information (PHI)
  3. A specific description of the information to be used or disclosed, including the dates of service
  4. The purpose of the requested use and disclosure
  5. The expiration date or event
  6. The patient signature and date
  7. A statement that the patient may revoke the authorization and how
  8. A statement that signing the authorization is not a condition of getting treatment
  9. A statement that the information disclosed may be subject to re-disclosure by the recipient

(Numbers 7, 8, and 9 are included in the text of our standard form)

Consent to Release Information (Word Doc)57.65 KB
Consent to Release Information (Adobe PDF)63.13 KB

Health and Wellness Center

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See Also

  • Student Health Insurance
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  • Health Education
  • Red Folder: Provide assistance to distressed students
Pennsylvania map showing Penn State's campuses with Penn State Altoona highlighted

Penn State Altoona

A full-service, four-year, residential campus located less than 45 miles from the research campus at University Park. Offering 21 four-year degrees and the first two years of over 275 Penn State majors.
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Give Visit Apply
  • This is Penn State Altoona
    • Penn State Altoona At a Glance
    • Mission, Vision, and Values
    • Our History
    • Campus Map
    • College Leadership
    • Current Weather Conditions
    • Livestream
  • Academics
    • Majors
    • Academic Calendar
    • Out-of-Class Learning
    • Eiche Library
    • Learning Resources Center
    • Registrar
    • Academic Advising
    • Honors Program
    • Campus Closures
  • Admissions
    • Visit Us
    • Information for First-Year Students
    • How to Apply
    • Accepted Students
    • Experience Altoona
    • Virtual Tour
  • Tuition & Financial Aid
    • Scholarships and Awards
    • Grants
    • Loans
    • Work-study
    • Financial Aid Basics
    • Tuition and Costs
    • Financial Aid Information
  • Student Success
    • Center for Student and Civic Engagement
    • Health and Wellness Center
    • Student Diversity and Inclusion Programming
    • International Student Services
    • Housing
    • Parking
    • Police and Safety
    • Career Services
    • Diversity at Penn State Altoona
  • Research & Engagement
    • Undergraduate Research and Creative Inquiry
    • Faculty Research Resources
    • Community-Based Studies
    • Internships
    • Study Abroad/Study Away
    • Internal Grants and Awards
  • Athletics
    • Schedule
    • Facilities
    • Recreation and Club Sports
    • Staff and Coaches Directory
    • Athletic Training and Sports Physicals
    • Athletics News
    • Camps and Clinics
    • Hall of Fame
  • Stay Connected
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    • Offices and Divisions
    • Campus Calendar
    • PSUAlert Text Messaging Service
    • COVID-19 Information
    • Penn State Altoona Connect
    • Penn State Student Engagement Network
Penn State University
3000 Ivyside Park, Altoona, Pennsylvania 16601 814-949-5000

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