Sending and Releasing Records
To protect your privacy and confidentiality, in most situations CAPS is required by law to obtain your written permission to use, disclose, or release your protected health information and/or treatment records.
We would be happy to send your CAPS records to a third party, with your written consent. Many other agencies, including Purdue University Health Center, use forms that do not meet our requirements, so using the Purdue CAPS Authorization for Use, Disclosure and/or Release of Protected Health Information will make it possible for us to release your records most quickly.
Please print our form, fill it out with your complete identifying information, complete contact information for the party you wish to receive the records, sign, and return by fax or U.S. Postal Service to:
- Megan L. Burton, LCSW
- Care Manager
- Counseling and Psychological Services (CAPS)
- 601 Stadium Mall Drive, Room 246
- West Lafayette IN 47907-2052
- FAX: 765-496-2139
The Authorization Form is viewable in .pdf format.
If you do not have Acrobat Reader for .pdf files, you can download it HERE for free.
Ms. Burton may try to reach you if she has any questions, so please tell us your preferred contact method. You are welcome to call Ms. Burton if you have any questions: 765-494-6995, or firstname.lastname@example.org. We will not send confidential information over email, and we request that you do not use email to send us a completed form.