DEPARTMENT OF OCCUPATIONAL THERAPY & OCCUPATIONAL SCIENCE CONSENT FOR HEALTH INFORMATION SHARING I, , consent to the disclosure of my protected health information by the Department of Occupational Therapy & Occupational Science for the purpose of securing my fieldwork placement. I understand that my acceptance as a fieldwork student in the setting to I have been assigned is conditional on the release of this information. This information may be shared by the Department of Occupational Therapy & Occupational Science by FAX or through the postal service in circumstances where (or when) I am unable to personally supply the placement site with the information. My health information” means my immunization record, including measles, mumps, “protected rubella, varicella, and Hepatitis B (or the signed Declination Statement) and the Mantoux PPD Test for tuberculosis or last chest x-ray, if applicable. Signature of Student Name of Student Date
DEPARTMENT OF OCCUPATIONAL THERAPY & OCCUPATIONAL SCIENCE CONSENT FOR HEALTH INFORMATION SHARING I, , consent to the disclosure of my protected health information by the Department of Occupational Therapy & Occupational Science for the purpose of securing my fieldwork placement. I understand that my acceptance as a fieldwork student in the setting to I have been assigned is conditional on the release of this information. This information may be shared by the Department of Occupational Therapy & Occupational Science by FAX or through the postal service in circumstances where (or when) I am unable to personally supply the placement site with the information. My “protected health information” means my immunization record, including measles, mumps, rubella, varicella, and Hepatitis B (or the signed Declination Statement) and the Mantoux PPD Test for tuberculosis or last chest x-ray, if applicable. Signature of Student Name of Student Date
consent-for-health-information-sharing.docx