Counseling Services Office

Authorization to Exchange Confidential Information

    Oklahoma School of Science and Mathematics
    1141 North Lincoln Boulevard
    Oklahoma City, OK 73104
    (405) 521-6436

    This authorization applies to inspecting, copying, mailing, and discussing:

    Health Care Information and RecordsEducational/School Information and RecordsFinancial Information and RecordsSocial Services Information and RecordsLegal Information and RecordsOther:

    Mental illness and/or psychiatric disordersAlcohol and/or drug abuseSexually transmitted diseases, including HIV/AIDS

    This authorization expires in one (1) year, but may be revoked at any time, except to the extent the holder of the information/records has already taken substantial action in reliance on the authorization. Any further disclosure may be made only as provided by law. A photocopy of this form is as valid as the original. I understand that the information and records to be released are protected under Federal Confidentiality Regulation and other federal law.
    My/Our signature(s) below authorize(s) release of all such records and information.