Title

Consent for Release of Confidential Health Information

Learner Name (PRINT)                                                 Year/Class                          Date

All of the clinical sites utilized by the Physician Assistant Program require documentation of medical status of the learners that will be performing experiential learning activities at those sites. In order for the Physician Assistant Program staff to provide the required information to the sites, learner permission is needed to permit the Physician Assistant Program to release the necessary information to the clinical sites.

I,                                                                                                        , authorize the Ithaca College Master of Science in Physician Assistant Studies Program staff to release my medical health form checklist to the clinical sites I will be rotating through during the Didactic and Clinical Phase. I understand that information will be sent only to those facilities requiring documentation of my medical status.

Learner Name (Signature)

Date

Learner Name (Print)