Houston Independent School District



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| |HOUSTON INDEPENDENT SCHOOL DISTRICT |

| |Office of Special Education Services |

| |4400 West 18th Street |

| |Houston, TX 77092 |

| |713-556-7025 |

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Consent for Release of Medical Information

1. Your signature on this form authorizes the release to Houston Independent School District of medical, psychological, and other information regarding your child’s diagnosis, limitations, and other data necessary to serve your child in the Homebound/Hospital Program.

2. Your signature on this form authorizes the Houston Independent School District to release and discuss information about your child to those health care providers.

3. A new and updated Physician’s Recommendation form is required at the beginning of each term for those students in need of long-term Homebound/Hospital services.

4.After signing the Parent Release of Information (below), HISD will transmit the Physician’s Recommendation form to your child’s attending physician for completion.

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|This consent is given for | | | | |

| | |Student | |Date of Birth |

I authorize the physician(s) listed below to release and/or exchange information with HISD Physician Medical Consultant and HISD Special Education personnel regarding course of treatment.

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|Physician | |Specialty and ID# | |Address | |Phone | |Fax |

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|Physician | |Specialty and ID# | |Address | |Phone | |Fax |

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|Physician | |Specialty and ID# | |Address | |Phone | |Fax |

I have been fully informed that the information sought will be used for the purpose of determining eligibility for Homebound/Hospital education services. I consent to the release of this information to the Houston Independent School District. I understand this consent is voluntary and may be revoked at any time to the extent action has not been taken prior to my revocation. Additionally, I understand that my consent will permit HISD to obtain my child’s individually identifiable medical information. I understand that information released may longer be protected by HIPAA (the federal privacy regulations governing medical information), however, the information will still be protected by the Family Educational Rights to Privacy Act, (FERPA) that protects the privacy of personally identifiable student information held in a student’s education records. .Finally, I understand that my refusal to consent may result in an inability of HISD to determine eligibility for Homebound/Hospital services and the denial of Homebound/Hospital Services to my child.

□ Yes, I do consent to communication between school district employees and home health caregivers. This consent may be revoked at any time.

□ No, I do not consent to communication between school district employees and home health caregivers.

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|Signature of Parent, Adult Student, Legal Guardian, | |Title | |Date |

|Surrogate Parent | | | | |

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|Signature of Interpreter (if required) | |Title | |Date |

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