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

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