Authorization to Release Medical Information From the Health Center

Authorization to Release Medical Information From the Student Health Center:

(Request Records from the Health Center be sent to another Provider)

  1. To receive a copy of your Texas State University Health Center Medical Record, an authorization to release medical information must be signed and dated by the patient or the patient's legal guardian; please click on the link below to download and print out the form.
    1. Release of Information Form
    2. Proper photo identification must be presented at the time of request.
      1. If the form is submitted in person at the SHC, please present your Student ID Card or Driver’s License.
      2. If the form is mailed or faxed, please include proper photo identification (Student ID Card or Driver’s License) with the Authorization.
    3. All sections of the form should be completed; including initials to applicable information in section #4 and sign/date. Please note, the SHC does not accept electronic signatures
  2. Completed forms can be submitted via Fax, Mail, or In-Person.
    1. Fax: 512.245.9288
    2. DO NOT email your Release of Information.
    3. Mail: Texas State University
      Student Health Center
      Attn: HIM Dept. – ROI
      601 University Drive, San Marcos, TX 78666
    4. In Person: Student Health Center; Suite 204
  3. Texas Law requires us to provide copies of health information within 15 days. If payment is required, records will be provided within 15 days after receipt of payment.
  4. Requestors may be charged a fee to cover the expense for providing copies of health information. Any applicable fees are expected to be prepaid PRIOR to copies being released. The first 10 pages are at no charge and $.10 per page after the 10th page; plus $5.00 to mail or fax long distance.

Please direct any questions about the Release of Information process to the Health Information Management Department at the Student Health Center; 512.245.8437.