Health Information Release Forms

What You Should Know

Healthcare providers are required to obtain signed authorization to release health information (exceptions are outlined in our Privacy Notice). Please use and submit the form appropriate for your request.

Questions can be directed to Health Records at 323.343.3337.

Release of Health Information Request

This form is used to request the Student Health Center (SHC) release information from your SHC health records to a person/provider/entity of your choosing.

Health Information Release Request and Authorization

Health Information Request

This form is used to request health records from an outside provider be released to the Student Health Center (SHC) and incorporated into your SHC health record.

Request and Authorization for Health Information