Waiver; health information; form

Each public postsecondary education management board shall require each institution under its jurisdiction to make available to every student a form on which the student may authorize the institution to disclose otherwise protected health information to persons designated by the student in the event of a mental health crisis or situation where the student poses a risk to himself or others. The form shall be presented as follows: Authorization to Release Information in the Event of a Mental Health Crisis Student Name Student ID Number Date of Birth Education Institution Name Purpose of Authorization In compliance with applicable privacy laws, this form allows the above-named institution to notify my parent(s), guardian(s), or other designated individuals in the event of a mental health crisis or situation where I may pose a risk to myself or others. Section 1: Designated Contact(s) I hereby authorize the institution to contact the following individual(s): 1. Primary Contact Name: Relationship to Student: Phone Number: Email Address: 2. Secondary Contact (Optional) Name: Relationship to Student: Phone Number: Email Address: Section 2: Scope of Information to Be Shared I authorize the education institution to share the following types of information with the designated contact(s): •General nature of the mental health crisis. •Actions taken by the education institution (i.e. hospitalization, counseling referral). • Recommendations for follow-up care. I understand that specific diagnoses or treatment details will not be disclosed unless otherwise authorized or required by law. Section 3: Duration of Authorization This authorization will remain in effect (select one): [ ] Until the conclusion of my enrollment at the education institution. [ ] Until I submit a written request to revoke this authorization. Section 4: Student Acknowledgment I understand the following: •I am voluntarily granting this authorization. •I have the right to revoke this authorization at any time by submitting a written request to the education institution. •Revocation of this authorization will not apply to information already shared under this consent. •This authorization does not require the education institution to notify my designated contact(s) unless deemed necessary. Signature of Student: Section 5: University Representative Acknowledgment Signature of Representative: Printed Name: Title: Date: Privacy Notice The information disclosed under this authorization is protected by federal and state privacy laws. The education institution will use reasonable efforts to safeguard your information in accordance with these laws.