• Authorization for Release or Disclosure of Protected Health
  • Authorize disclosure of your health information — The Health Insurance Portability and Accountability Act requires all health care providers to protect your health record privacy.  For this reason, you must provide specific permission for the release or disclosure of this information to allow DUHS to discuss your health information with anyone EXCEPT in an emergency situation.
    Please be aware that a visit to the health center does NOT constitute a reason for absence in class or from class work unless specifically prescribed by a DUHS provider.  For more information regarding this form, please contact Health Services at 973-408-3414 during clinic hours.

Process for requesting release of your Medical Record

  1. Authorization for Release or Disclosure of Protected Health
  2. Return the form (and check if applicable) to the Medical Records Secretary at the above address.

Rush Request

If urgent release of documents is requested and possible (within 24 hours), an additional service fee of $10 will be applied and must be paid for by credit card at the time of request. Only American Express, Visa and Mastercard are accepted.

If you have any questions about the information contained in your chart, please email them to the Medical Records Secretary at health@drew.edu