Authorization For Release Of Medical And Educational Information And Records
ADVERTISEMENT
1
2
3South Bend Community School Corporation
Special Education Department
215 S. Dr. Martin Luther King Jr. Blvd, South Bend, IN 46601
Ph: 574.393.6119 Fax: 574.283.8105
Authorization for Release of Medical and Educational Information and Records
Student Name: ________________________________________
Date of Birth: _____________
Student ID:____________ School: __________________________
Grade: _______________
I authorize the South Bend Community School Corporation and the Agency listed below to
exchange the medical and/or educational information and records (described more particularly below)
regarding the above-named student to one another:
Contact Person: __________________________________
South Bend Community School Corporation
School: __________________________________
Tel: _______________ Fax: _______________
Agency: ____________________________
Contact Person: ____________________________
Address: ________________________________________________________________________
Phone: ____________________________
Fax Number: ______________________________
Records to be Released by SBCSC: Please identify the type of records to be released from the
SBCSC to the Agency.
□ Medical and health records
□ Grades, transcripts, course performance
□ Mental health records
□ Test scores
□ Psychiatric evaluations/reports
□ Attendance records
□ Psychological evaluations/reports
□ Disciplinary records
□ Drug/alcohol records
□ Scholarship and grant applications
□ Social work reports
□ Special education records, including an
□ Speech/language records
Individualized Educational Plan (IEP)
□ Occupational and/or physical therapy
□ Teacher, counselor, staff observations, ratings,
records
and recommendations
□ Correspondence
□ Other (please describe): __________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Unless otherwise noted above, the records to be exchanged are those created between
__________(month/year) and __________(month/year).
Records to be Released by Agency: Please identify the type of records to be released from the
Agency to the SBCSC.
□ Medical and health records
□ Drug/alcohol records
□ Mental health records
□ Social work reports
□ Psychiatric evaluations/reports
□ Speech/language records
□ Psychological evaluations/reports
□ Occupational and/or physical therapy records
□ Correspondence
□
Other (please describe): __________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
8/6/10
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business