Form Hsf-121 - Authorization For Release Of Health Information

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Fresno Unified School District
Authorization for Release of Health Information
A. STUDENT / PATIENT INFORMATION
Name:
_____________________________________________________________________________
Last
First
M.I.
Date of Birth:
FUSD Student Number:
____________________
________________
B. INFORMATION TO BE RELEASED FROM:
 Clovis Community Hospital
_________________ School District
 Fresno Community Hospital
 CCS – Ca. Children’s Services
 Kaiser Permanente MC
 CCS Medical Therapy Unit
 Saint Agnes Medical Center
 CVRC-Central Valley Regional Cnt.
 University Medical Center
 EPU - Exceptional Parents Unlimited
 UMC Children’s Health Center
 Fresno Co. Health Services Agency
 Children’s Hospital of Central CA
 Fresno Co. Office of Education
 Charlie Mitchell Clinic
 Rehabilitation
 PT/OT
 Speech and Hearing
 Special Clinics
 Genetics
 Other (list):
 Physician / Clinic / Other:
______________________________________________________________
 Physician / Clinic / Other:
______________________________________________________________
C. INFORMATION TO BE RELEASED TO AND USED BY FUSD:
School / Dept: ____________________
Contact Person: ______________
Address _____________________ City __________ State ___ Zip _______
Phone: ___________ FUSD Health Services Confidential FAX: (559) 457-6095
D. PURPOSE OF THE REQUESTED INFORMATION
 Forwarded at the request of the Parent / Legal Guardian
 Assist in planning appropriate educational program / accommodations
 Other: __________________________________________________
E. TYPE / DESCRIPTION OF INFORMATION REQUESTED
 Immunization Record
 Operative Reports
 Amb. Clinic Summary
 Physician Orders
 Lab / X-ray Results
 Appointment Dates/Times
 History and Physical
 Discharge Summary
 Mental Health Records
 Consultation Reports
 Other: ____________________________________________
HSF-121 (Rev. 1/04)
Side 1 of 2

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