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This process ensures that any release of information is conducted in compliance with applicable federal regulations and institutional policies.) /Pg 9 0 R /K [3] >> endobj 30 0 obj << /Type /StructElem /S /P /P 24 0 R /E (Instructions) /Pg 9 0 R /K [4] >> endobj 31 0 obj << /Type /StructElem /S /P /P 24 0 R /E (Complete each blank field, sign and return this form to healthcompliance@dyu.edu.) /Pg 9 0 R /K [5] >> endobj 32 0 obj << /Type /StructElem /S /H2 /P 24 0 R /T (Student Information) /E (Student Information) /Pg 9 0 R /K [6] >> endobj 33 0 obj << /Type /StructElem /S /P /P 24 0 R /E (Name: Date of Birth:) /Pg 9 0 R /K [7] >> endobj 34 0 obj << /Type /StructElem /S /P /P 24 0 R /E (DYU Student ID: Phone:) /Pg 9 0 R /K [8] >> endobj 35 0 obj << /Type /StructElem /S /H2 /P 24 0 R /T (Authorization) /E (Authorization) /Pg 9 0 R /K [9] >> endobj 36 0 obj << /Type /StructElem /S /Figure /P 24 0 R /Pg 9 0 R /A [132 0 R 0] /K [10] >> endobj 37 0 obj << /Type /StructElem /S /P /P 24 0 R 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I understand that this information is protected under New York Public Health Law Article 27-F, and that:) /E (HIV/AIDS or sexually transmitted infection \(STI\) information By checking this box I specifically authorize the disclosure of information related to HIV/AIDS, including HIV test results, diagnosis, treatment, and any related information. 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I understand that these records are protected under federal law \(42 CFR Part 2\) and applicable New York State law, and that:) /E (Alcohol and/or drug use treatment records By checking this box I specifically authorize the disclosure of information related to alcohol and/or drug use diagnosis, treatment, or referral. 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