Information Exchange


HIPAA-Compliant Authorization for Exchange of Health & Education Information

Patient/Student Namerequired
First Name
Last Name
Must contain a date in M/D/YYYY format


Must contain only numbers
Must contain only numbers
to exchange health and education information/records for the purpose(s) listed below:
PURPOSE: The information will be used for the following purpose(s):


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.

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.