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505.2.3P - Prior Consent to Release Private Data To or From an Outside Agency/Person

505.2.3P - Prior Consent to Release Private Data To or From an Outside Agency/Person

Adopted:  January 1978
Revised:  May 2018

 

Download 505.2.3P - Prior Consent to Release Private Data To or From an Outside Agency/Person

 

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:

      __   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)____________________________

 

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