Consent to Release Personal Health Information

Please read this consent form carefully and be sure you understand it before clicking the "Submit Form" button below.

You may use this form to permit the release to yourself or a third party any personal health information that Health Services has on file for you (for example immunizations). Your health records will be kept secure a minimum of 10 years at which point your records will be destroyed in accordance with legislation.

Your request for information has been submitted to Health Services. This may take up to 5 business days to process this request.

Please notify us of any changes to the information in your consent form. Thank you.

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Personal information

Consent

I give permission for RRC Polytech Health Services to release my personal health information to:
(Please check all that apply)

Myself

The following individual or organization

The information should be released by:
(Please check all that apply)

Fax

Email address

I would like the following information released, if present in my file:
(Please check all that apply)

Records of any immunizations, serologic testing, tuberculin skin tests (TST or Mantoux tests) and other tests that may be in my file

The following specific information

If you have any difficulties completing this form, please email Health Services.

Health Services Records Request Form

Please read this consent form carefully and be sure you understand it before clicking the "Submit Form" button below.

Personal information

Consent

Forms