***PLEASE READ BEFORE SUBMITTING***
This authorization to receive or release medical information is being requested of you to comply with the terms of the Confidentiality of Medical Information Act of 1980, Section 56 et seq. of the California Civil Code. Release or transfer of the specific information to any person or entity not specified herein is prohibited. An additional written consent must be obtained for a proposed new use of information or for its transfer to another person or entity. Release of records obtained from a person or entity other than UCSB Student Health Services is prohibited.
Access to student records and documents must be controlled to ensure integrity, security, and confidentiality. As a student at the University of California, Santa Barbara, the confidentiality of your student information is protected in accordance with the federal Family Educational Rights and Privacy Act (FERPA) of 1974 and University of California, Santa Barbara Policy and Procedure “Student Education Records – Disclosure of Information” issued March 2004 (available from the UCSB Registrar).
Unauthorized use, removal, defacement, or alteration of any physical record or computerized data is prohibited. Providing access to student records or information contained in this application to unauthorized persons is also prohibited.
I have read and understand the information above, and by clicking "I AGREE" below give consent for the UCSB Office of Financial Aid and Scholarships SMERF Committee to consult with Student Health Services if relevant to the review of this application. I understand that this release is only in effect for the academic year in which it is enacted.