Adopted: January 1978
Revised: May 2018
Download 505.2.3P - Prior Consent to Release Private Data To or From an Outside Agency/Person
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Parent/guardian: This form allows information about your child to be exchanged. Please sign and return it to the school. |
Student’s full name_________________________________________ Date of birth __ __ -__ __-__ __ School_______________________________ Grade_______ |
Parent/guardian name
Parent/guardian address
I authorize
school district name and/or number and person responsible
address
city state zip
phone number email fax number
(check as needed) ______ to release information to:
______ to obtain information from:
name title
organization
address
city state zip
phone number email fax number
The purpose for the request
School records may be examined by parent/guardian, or student age 18 or older. A copy of this consent form will be provided upon request. Please release the following:
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__ Test results and other non-directory information in the cumulative folder __ Chemical abuse/dependency report(s) __ Health record __ Teacher, counselor, staff observations __ Child study/special education records (including related services) |
__ Social work reports __ Psychiatric reports __ Medical report (including related services) __ Psychological reports __ Other (specify) ____________________________________________ ___ Other (specify)____________________________
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I understand this authorization takes effect the day I sign it. It expires on ________________
(month, day, year)
or no more than one year from the date of my signature. I also understand that I may change this authorization at any time by notifying the school principal or staff member identified above. I may refuse to sign this authorization and it will not affect my child’s ability to receive educational services. I understand that I am entitled to a copy of this authorization. I understand that the laws that protect the information disclosed may allow or require the re-disclosure of the information, but only as permitted by law.
HIPAA STATEMENT: If this consent form provides for the release of "protected health information" (PHI) as defined by the Health Insurance Portability and Accountability Act (HIPAA), I understand that redisclosure of PHI by the recipient may no longer be protected by HIPAA. Treatment, payment, enrollment or eligibility of benefits from a health plan or health care provider may not be conditioned on obtaining this consent.
___________________________________________________ ___________________________________________________
Signature of parent/guardian/student age 18 or older Date
Photocopy valid as original.
Copies: __ Child Study file (if one exists) __ Cumulative folder __ Other