Information Exchange

Required

HIPAA-Compliant Authorization for Exchange of Health & Education Information

Patient/Student Namerequired

First Name

Last Name

Date of Birth

Must contain a date in M/D/YYYY format

I HEREBY AUTHORIZE:

Healthcare provider's name & titlerequired

Healthcare provider's phone numberrequired

Must contain only numbers

Healthcare provider's addressrequired

and

Name and title of school officialrequired

School Official's phone numberrequired

Must contain only numbers

School or District Addressrequired

to exchange health and education information/records for the purpose(s) listed below:

The health information to be disclosed will consist of:

The education information to be disclosed will consist of:

PURPOSE: The information will be used for the following purpose(s):

Educational evaluation and program planning.

Health assessment and planning for health care services and treatment in school.

Primary healthcare services and medical treatment decisions.

Other

Define Other listed above

AUTHORIZATION

This authorization is valid for one calendar year from the date signed. I understand that I may revoke this authorization at any time by submitting written notice of the withdrawal of my consent. I recognize that these records, once received by the school district, may not be protected by the HIPAA Privacy Rule, but that they will become education records protected by the Family Educational Rights and Privacy Act. I also understand that if I refuse to sign, such refusal will not interfere with my child's ability to obtain healthcare.

PARENT ACKNOWLEDGEMENTrequired

STUDENT ACKNOWLEDGEMENTrequired

If a minor student is authorized to consent to health care without parental consent under federal or state law, only the student shall sign this authorization form. In Connecticut, a competent minor, depending on age, can consent to outpatient mental health care, alcohol and drug abuse treatment, testing for HIV/AIDS, and reproductive health care services.