Baylor University Health Center (STUDENT)
Privacy Notice & Consent for Disclosure of Health Records and Information
I understand that as part of the provision of health care services, Baylor University Health Center creates
and maintains health records and other information describing among other things, my prescription drug
history, my health history, symptoms, examination and test results, diagnoses, treatment, and any plans
for future care or treatment.
By signing this form, I consent to the use and disclosure of all medical records maintained by the Baylor
University Health Center and my protected health information for the purposes of treatment, payment
and health care operations. I have the right to revoke this consent, in writing, except where disclosures
have already been made in reliance on my prior consent.
This consent is given freely with the understanding that:
1. Any and all records, whether written or oral or in electronic format, are confidential and will
only be disclosed for the purposes of treatment, payment or health care operations and as
otherwise provided by the Family Educational Rights and Privacy Act (FERPA) and other
2. A photocopy or fax of this consent is as valid as this original.
3. I have the right to request that the use of my health records and protected health information,
which is used or disclosed for the purposes of treatment, payment or health care operations
be restricted. I also understand that the Baylor University Health Center and I must agree to
any restriction in writing that I request on the use and disclosure of my health records and
protected health information; and agree to terminate any restrictions in writing on the use and
disclosure of my Protected Health Information which have been previously agreed upon.