Get Limited Authorization Form - Private - Berkeley Study Abroad

Completing the Limited Authorization Form for the Berkeley Study Abroad program is essential for ensuring that your health information is properly managed during your stay abroad. This guide will walk you through each section of the form, providing clear and supportive instructions to help you navigate the process confidently.

Follow the steps to successfully complete the Limited Authorization Form

1. Press the ‘Get Form’ button to access the Limited Authorization Form and open it in your preferred online editor.
2. Begin filling out the form by entering your name in the designated section, identifying yourself as the 'Student' who is participating in the EAP program.
3. In the next section, provide the name of the specific EAP program you are participating in, including the country and host university for clarity.
4. Authorize the disclosure of your health information by selecting either 'all health information' or specifying particular records. Ensure you check the appropriate boxes based on your health history.
5. Explicitly authorize the release of sensitive information (if applicable) by checking the boxes for mental health treatment, HIV test results, or alcohol/drug treatment information.
6. Should you wish for an emergency contact to be notified, indicate this by completing the respective section, ensuring this aligns with your general welfare while abroad.
7. Sign and date the form at the bottom. This confirms your understanding and agreement to the terms laid out in the document.
8. Once completed, provide copies of the signed authorization to each relevant healthcare provider you have visited in the last 12 months.
9. Finally, send a copy of the completed form to the University of California Education Abroad Program by the deadline indicated in the EAP Pre-Departure Checklist.

Complete your Limited Authorization Form online today to ensure your health matters are appropriately addressed while studying abroad.