Authorization For Release Of Medical And Educational Information And Records (Page 2 of 3) in pdf

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.

Initial Below

__________ 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

□

Other: __________________________________________________

□

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

authorization.

__________ 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

9/19/14

Authorization For Release Of Medical And Educational Information And Records Page 2