This form is required by Student Health Services. All students must have a completed form on file. This form must be completed by a healthcare provider and signed by the student or a guardian if the student is under the age of 18.
Graduate students: • CGU • KGI PharmD • KGI • Robert Day School
Release of information
Release of Information Form (use if sharing SHS records with parent, dean or provider or if sending records from home provider to SHS)
- Student Health Services strictly adheres to all state and federal regulations pertaining to confidentiality of medical records.
- A release of information form must be completed when a student makes any request for their patient information to be released to parent, family practitioner, referral doctors or anyone else.
- This form or a written request (must include DOB/School attended/specific information requested and where to send or Fax information/signed and dated) must be completed by an enrolled student requesting copies of his/her medical file.
- Copying charges may be applied and billed to your student account.
- The completed release form or written request may be mailed, faxed or hand delivered to Student Health Services and the request will be handled as promptly as possible.
- Fax requests for records by another physician must be accompanied by a signed request for release of medical records and will be sent at no charge, fax: (909) 621-8472.
- We do our very best to see that all requests are addressed promptly. However, during the summer break (June – August) it may take up to 15 business days to provide the information requested.