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Incomplete or improperly filled out forms may be returned.

1.  Put your name and date of birth in the appropriate blanks.

2.  Put the name of the office or individuals with whom you would like CAPS to communicate where it says, "I hereby authorize the Counseling and Psychiatric Service at Georgetown University to exchange protected health information below with these parties: ____________________________"

3.  Where it says "I authorize the disclosure of the following types of records created from ________ to ________", the first date is the date of first contact with our office.  The second date will generally be "today."  Both dates must be filled in.

4.  Check the relevant boxes where it says

___ Attendance  (appointments scheduled and met; dates of service)
___ Treatment plan
___ Safety concerns (level of danger to self or others)
___ Treatment summary
___ Alcohol and other drug use
___ Academic related issues
___ Billing records
___ Written mental health records
___ Other:  ______________________________________

5.  Check the relevant boxes where it says:

The purpose of the Requested Use or Disclosure is: 
___ At the request of the patient
___ For continuity of care
___ For coordination of care     
___ To address academic concerns  
___For medical leave of absence or assessment for return
___Other:_____________________

6.  You do not have to fill out the following blank unless you want to:

Expiration Date: This authorization expires in 60 days from today?s date, or this earlier date:____________ , or when the following event occurs: _______________________________________

7.  Sign and date the form.

8.  Have a witness sign and date the form.