ࡱ> 796]  bjbjjj *)b)b66666JJJJ V4J.$<6"66    66     . y0 L 6 l IB :  BELLARMINE UNIVERSITY As of 9/1/2015 2001 NEWBURG RD, LOUISVILLE, KY 40205 502-272-8313 AUTHORIZATION FOR RELEASE OF INFORMATION FROM STUDENT HEALTH RECORD (Short Form) Name (please print complete name) _________________________________ Bellarmine ID-_____________ Date of Birth________________________________________ Address____________________________________________ _____________________________________________ City_______________________ State_____________ Zip Code____________ Phone Number_______________________________________ Email Address_______________________________________ Program of Study_____________________________________ I hereby authorize disclosure of my health record information as follows: (Check all that apply) Complete Medical Record Immunization Record Other Information (Please specify)____________________________________________ ________________________________________________________________________ The purpose of this release is for:: Transfer of records to another provider Attorney Employment Parent Other, indicate -________________________________________________________ Signature___________________________________________________________ Date_______________ (/58=>acdhkpqr  ) * A B D E K M ~~~njf~`f h\CJheheYjheYUmHnHtHu heYCJ hzCJ h hehHhe5CJaJ heCJh h CJaJh hmCJaJh CJaJh hSgCJaJhv?he5CJaJhz5CJaJhv?5CJaJhHhSg5CJaJhv?5CJ$aJ$#>dqr % & \ ] > ? t u gde$a$gde    ( ) ekd$$Ifl 0 64 layte $Ifgdegde) * > ? @ 5^kd$$IflLD064 layte $Ifgdegde^kd$$Ifl 064 layte   * + ^kd$$Ifl 064 layte $Ifgdegde+ , 5 6 7 B C 5^kdz$$Ifl 064 layte $Ifgdegde^kd$$Ifl 064 layteC D L M gde^kd$$Ifl 064 layte(/ =!"#$% $$If!vh#v :V l0 65 4yte{$$If!vh#v :V l065 4yte$$If!vh#vD:V l065D4ayte{$$If!vh#v :V l065 4yte{$$If!vh#v :V l065 4yte{$$If!vh#v :V l065 4yte{$$If!vh#v :V l065 4ytes2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nHsH tH@`@ eNormalCJ_HaJmH sH tH DA D Default Paragraph FontVi@V  Table Normal :V 44 la (k (No List HH Sg Balloon TextCJOJQJ^JaJN/N SgBalloon Text CharCJOJQJ^JaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vc:E3v@P~Ds |w<   ) + C  8@n(  6  "?B S  ?Dot/1ac333> &,p((**))**,,AADKLLM v_ O};XC6DWXSW TSgv?m0azeYe \%lCH@@UnknownG*Ax Times New Roman5Symbol3. *Cx Arial5. .[`)TahomaA$BCambria Math"hl2fgl2fgrsF55243HP ?e2!xx $JEFFERSON COLLEGE OF HEALTH SCIENCEScidrw1rlove@bellarmine.eduOh+'0 $0 P \ h t(JEFFERSON COLLEGE OF HEALTH SCIENCEScidrw1 Normal.dotmrlove@bellarmine.edu2Microsoft Office Word@@T@ql@ql5՜.+,0  hp|  CHS %JEFFERSON COLLEGE OF HEALTH SCIENCES Title  !"#$%'()*+,-/0123458Root Entry F:Data 1TableWordDocument*SummaryInformation(&DocumentSummaryInformation8.CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q