I hereby authorize the MSCD Student Judicial Officer to:

Release the following information to:

Request the following information from:

Name of Health, or other facility, physician, counselor, other:

City State Zip Code

SPECIFIC INFORMATION to be released:

TYPE OF INFORMATION to be released (e.g. Verbal Communications between above agencies or individuals, Alcohol/Drug History, Psychological History):

I authorize the release of my records in accordance with the specifications listed above, and understand that I may revoke this authorization to release/request information by giving written notice to the MSCD Student Judicial Officer, Campus Box 74, PO Box 173362, Denver, CO 80217-3362. Without such revocation, this authorization will expire on (date) (or ninety days from the date of my signature). I also herewith release the MSCD Student Judicial Officer and my attending provider from all liability and all claims of any nature whatsoever pertaining to disclosure of information contained in my records.

NOTICE: This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal regulations prohibit you from making further disclosure of this information without the specific written consent of the person to whom it pertains.