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)
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