Authorization for Release of Health Information
Authorization for Release of Health Information
A. STUDENT / PATIENT INFORMATION
Name:
LAST FIRST MI
Date of Birth: Sex: M F Currently Attending School At:
B. INFORMATION TO BE RELEASED FROM ((as needed):
___ ______________________ School District ___ Kaiser Permanente
___ California Children’s Services (CCS) ___ Dameron Hospital ___ Genetics
___ CCS Medical Therapy Unit ___ St. Joseph's Hospital ___ PT / OT
___ Valley Mountain Regional Center (VMRC) ___ Children's Hospital Central CA ___ Rehabilitation
___ San Joaquin General Hospital ___ UC, Davis Medical Center ___ Special Clinics
___ Doctor's Hospital Manteca ___ Shriner's Hospital for Children ___ Speech and Hearing
___ San Joaquin County Office Education ___ Oakland Children's Hospital ___ Other: ___________
___ Lucile Packard's Children's Hospital ___ UCSF Medical Center
___ Physician / Clinic / Other:
` ___ Physician / Clinic / Other:
C. INFORMATION TO BE RELEASED TO AND USED BY Manteca Unified School District
School/Department: Manteca Unified School District - Health Services
Address: Po Box 32 City : Manteca State: CA Zip: 95336
Phone: 209-858-0782 Fax: 209-858-7513 Contact Person:
D. PURPOSE OF THE REQUESTED INFORMATION
___ Authorization forwarded at the request of Parent / Legal Guardian
___ Assist in determining most appropriate school education program / learning accommodations
___ Other:
E. TYPE / DESCRIPTION OF INFORMATION REQUESTED
___ Immunization Record ___ Operative Reports ___ Ambulatory Clinic Summary
___ Physician Orders ___ Lab Results / X-ray Reports ___ Appointment Dates/Times
___ History and Physical ___ Discharge Summary ___ Mental Health Records
___ Consultation Reports ___ Other:
F. SIGNATURE AUTHORIZING RELEASE OF INFORMATION
By signing below, I understand that the information released may include information regarding treatment, hospitalization, or outpatient care, including psychological/psychiatric impairment, drug abuse, or alcoholism unless otherwise excluded here _______________________________________________________________.
I also understand that the school district is responsible for maintaining confidential files for access and review by involved educational staff ONLY. Academic, psychological and health records are exchanged among California public schools. Unless otherwise provided in the Authorization or permitted or required by law, no further disclosure of your child's health information will be made by the District without your express authorization. If you have authorized the disclosure of your child’s health information to a person or entity that is not legally required to keep it confidential, the information may be re-disclosed and may no longer be protected by state or federal law.
G. AUTHORIZATION RESTRICTIONS
Your Authorization to release health information is voluntary and you can refuse to sign this authorization. Refusing to sign this Authorization will not affect the District’s commitment to provide a quality education for your child. However, without the proper health information, the District may not be able to properly plan and provide educational services for your child.
This authorization may be revoked, in part or in whole, at any time.
a. To revoke this Authorization with respect to the District, you must provide the District with a written request, signed by you, to revoke this Authorization. The revocation will take effect when the District receives your written request.
b. To revoke this Authorization with respect to the organization or individual listed in Section B, you must provide the organization or individual listed in Section B with a written request to revoke this Authorization. The revocation will take effect when the organization or individual listed in Section B receives your written request. Please provide the District with a copy of your request for revocation.
c. Any information disclosed before your written revocation is received by the District or the organization or individual listed in Section B may be used as permitted in the Authorization.
You have the right to receive a copy of this Authorization. Upon request, you will be provided a copy of this Authorization.
A photocopy or fax copy of the Authorization is as valid as the original.
H. RESTRICTIONS
California law prohibits the Manteca Unified School District (MUSD) from making further disclosure of my health information unless MUSD obtains another authorization form from me or unless such disclosure is specifically required or permitted by law.
I. RE-DISCLOSURE
I understand that MUSD will protect this information as prescribed by the Family Equal Rights Protection Act (FERPA) and that the information becomes part of the student’s permanent educational record. The information will be shared with individuals working at or with the School District for the purpose of providing safe, appropriate, and least restrictive educational settings and school health services and programs.
J. EXPIRATION OF AUTHORIZATION
Unless otherwise revoked, this Authorization expires ______________________(enter date). If no date is indicate, the Authorization will expire 12 months after the date of my signing this form.
( See Attached Addendum for Release of Information concerning HIV and/or AIDS status
I have read and understand the “Authorization Restrictions and Rights” on this form which includes my right to refuse to sign this authorization, to revoke this authorization, and to receive a copy of this authorization.
Signature of Parent / Legal Guardian Date
______________________________________________________
Signature of Witness Date
Z\\disfile.\users\pnahhas\My Documents\FORMS\Release of Information\Authorization for Release of Health Information 7-07.doc
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- michigan department of education local district
- michigan intermediate school districts map
- st joseph school district summer journey don t delay
- school district code list michigan
- st joseph county intermediate school district mi name of
- dtmb 0292 application for eligibility to receive federal
- cs 214 position description form us
- volunteer opportunities troy counseling department
- arraignment disclosure form
- authorization for release of health information
Related searches
- importance of health information management
- types of health information systems
- examples of health information systems
- list of health information systems
- importance of health information system
- salary of health information technologist
- impact of health information technology
- components of health information system
- journal of health information management
- purpose of health information systems
- release of medical information form
- examples of health information technology