School/ Daycare Authorization

School/ Daycare Authorization
Parent/ Legal Guardian's Name*

First NameLast Name
Patient's Name*

First NameLast Name
Patient's DOB*

MonthDayYear
Date
I, {parentLegal}, authorize my provider to release {patientsName} on {patientsDob}'s medical records to the district's health and/ or administrative personnel and/ or daycare provider.

The following protected health information may be disclosed:
Check all that apply*

ImmunizationsHealth AppraisalsPast/ Current Medical Condition (and its impact on school/ daycare attendance, school programming, and/ or PT, OT, ST needs)Medical AdministrationSports ParticipationOther
The protected health information may be used, disclosed, or received for the following purpose(s):
Check all that apply*

For compliance with school/ daycare requirementsTo develop care or therapy plans for routine and emergent school/ daycare managementTo design appropriate educational programsTo assess the impact of the medical condition(s) on school/ daycare attendance and/ or programmingTo share school/ daycare observations/ concerns surrounding behaviorTo assess a medical basis for modification of transportation and/ or home tutoringTo assess the ability to participate in physical education/ sportsMedication delivery and/ or therapy prescriptions for PT, OT, STAt parent's/ patient's request with no specified purposeOther
Please select one:
This authorization is valid for the entire academic school year of
School Year
To:
School Year
This authorization shall expire on the date of
MonthDayYear
Expiration Date
I acknowledge that I have the right to revoke this authorization at any time by sending written notification to my provider's office.

I understand that the revocation of this authoriaztion is not effective if my provider has used the authorization for disclosure of the Protected Health Information before receiving my written revocation notice.

I understand that any Protected Health Information disclosed as a result of this Authorization to anyone not covered by the state and federal privacy laws may be sujbect to redisclosure and may no longer be protected by federal or state law.

I understand that my child's treatment is not dependent on my agreement to release or withhold information.
Signature of Parent or Legal Guardian*

Clear
Relationship*
Date*

MonthDayYear
Date
Your Email*
example@example.com
YOU MAY REFUSE TO SIGN THIS AUTHORIZATION
Should be Empty: