My USC Lancaster

*Required fields

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Student's Name *

Address *

Address, City, State, Zip

Phone Number *

(000) 000-0000

Date of Birth *

0/0/0000

I hereby authorize

Counselor Name *

of The University of South Carolina to use or disclose the following specific health information about myself to

Preferred Destination *

I authorize the following information about myself to be released/disclosed: *

Assessments (History, Symptoms, Diagnostic)Treatment PlansProgress NotesOther

If other is selected please explain

I understand that I may revoke this authorization at any time. If not previously revoked, this authorization will terminate on the following date, event or condition:

Date/Event/Condition

If no date or event is listed, this authorization will automatically terminate within 60 days from today.

The University of South Carolina, its employees, faculty, and officers are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.

Full Name *

Signature *

Please type your full name above as your electronic signature

Date *