Unless otherwise noted above, the records to be exchanged are those created between
___________________ (month/year) and _________________ (month/year).
Purpose of Disclosure: The purpose of this disclosure is to:
Authorization for Release of Protected Health Information
Please initial next to each paragraph below in order to allow the release of the protected health
information described on page one (1) from the Agency listed above to the South Bend Community
School Corporation under the Health Insurance Portability and Accountability Act of 1996.
__________ I understand that the information provided may include, when applicable, information
relating to communicable diseases such as sexually transmitted disease, Human
Immunodeficiency Virus (HIV Infection, Acquired immune Deficiency Syndrome, or
AIDS Related Complex) and any other communicable disease. It may also include
information about behavioral or mental health services, and referral and/or treatment for
alcohol and drug abuse.
__________ I understand that if I give permission, I have the right to change my mind and revoke it.
The revocation must be in writing and delivered to the Agency listed above. I also
understand that such revocation will not affect any uses or disclosures already made
with my permission. I further understanding that the revocation will not apply to my
insurance company when the law provides my insurer with the right to contest a claim
under my policy.
__________ I understand that unless otherwise revoked by me, this authorization will expire on the
following date, event, or condition. If I fail to specify an expiration date, event, or
condition, this authorization will expire one year from the signature date.
One year after the student is no longer enrolled in a SBCSC school
Please specify expiration date, event, or condition
__________ I understand that authorizing the disclosure of this health information is voluntary. I need
not sign this authorization to ensure healthcare treatment; except, however, if my
treatment is for the sole purpose of creating health information for disclosure to the
SBCSC, the Agency listed above may refuse to treat me if I do not sign this
__________ I also understand that any disclosure of information carries with it the potential for an
unauthorized re-disclosure and that the protected health information disclosed pursuant
to this authorization is no longer protected by federal or state privacy rules. I also
understand that the confidentiality of this information when released to a public
educational agency, including the SBCSC, is protected as a student record under the