Release of Information Forms
For Counseling Services: Counseling Release of Information Form
For Medical Services: Medical Release of Information Form
The Dr. Bob Smith Health Center will not disclose your medical information to anyone unless YOU give your written permission for us to do so. This means we will not tell your friends, your roommates, the faculty, staff, or even family members about any of your appointments, phone calls to our nurses, or visits with our providers and staff unless we have received a signed copy of the release form accessed above.
After printing off, completing, and signing the Release of Information form, you may fax or email it to us: