Release of Information (ROI)

All treatment at the UCC is confidential. With a student’s written permission, in the form of a signed Release of Information Form (ROI), the UCC is able to share information about the student’s care with a specific person or agency, including a campus partner, off-campus provider, parent/guardian, etc. A ROI includes the person to whom the information will be released, the information to be released, the purpose of the release, and an expiration date.


If there is a valid ROI on-file with the UCC, we will be able to process a request to share information. If a request involves coordination of care with a new provider, a new ROI must be completed. If a ROI is expired it must be updated before information
can be released. Students can retract a ROI at any time by contacting the UCC.


Please note that the UCC does not email clinical records. Please provide a fax number to ensure timely delivery of your records. 


A blank ROI as well as pre-populated ROI forms that are commonly utilized are provided below for your convenience. Download the ROI that you need, complete the form, sign it, and return a copy to the UCC.


Care & Wellness Consultants
Sara Bea Accessibility Services
University Health Services
Athletics

ROI for off campus providers:
Primary care physician/pediatrician
Off-campus mental health provider
Blank