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Division of Student Affairs

Counseling Records Release Form

Counseling Records Release Form

To protect our patient’s confidential medical information, we must have a valid, complete, and legible authorization to disclose their health information.

Records can only be released by or to the patient with a signed consent form. If you are under 18, your parent/guardian must be the one to sign this form.

We require at least ten (10) business days advance notice to provide time to review the request, copy and prepare the medical record(s) for mailing, faxing or pick up.

UCM and many other organizations and individuals such as physicians, hospitals and health plans are required by law to keep your health information confidential. If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, it may no longer be protected by state or federal confidentiality laws.

Click the link below to launch our online records request form.

Counseling Records Release Form