Counseling & Human Development HOW TO FILL OUT THE RELEASE OF INFORMATION FORM

CHD Release of Information An original signed copy of this form is necessary for CHD to be able to communicate or share information about you with anyone else. Please read it carefully and ask questions if you have any.

Authorization This is where you specify what information you would like CHD to be able to share. Below are some examples of the types of information students sometimes choose to release. On your form, only include information specific to your case (some sample responses may not apply).

Who the release is for This is where you specify who you are granting CHD permission to communicate with. Below are some examples of people some students want CHD to share information with. List only the individual(s) pertinent to your current request.

Purpose of the release This is where you specify why you are granting CHD permission to communicate with a third party. Below are some examples of reasons some students want CHD to share information.

Expiration of the release The release will expire 1 year from the date of signature (unless you specify a date before then). You can also revoke authorization at any time.

Alcohol/Drug/HIV Please initial if you authorize CHD to release information pertaining to alcohol/drug treatment and/or HIV status. In these special cases your express consent is needed.

Sign and date Lastly, sign and date the form. If you are not physically at CHD you may forward an electronic copy; however, please also send the signed original to our office.

You’re finished! Please contact CHD if you have any additional questions. You can fax, mail, or hand deliver your signed release of information to our office. If you choose to fax or a copy, please also send the signed original. Counseling & Human Development 7 Rope Ferry Road, Hanover, NH Phone , FAX