Form Hsf-121 - Authorization For Release Of Health Information Page 2
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2Fresno Unified School District
F. PERSON AUTHORIZING RELEASE OF INFORMATION
I understand that the information released may include information regarding
treatment, hospitalization, or outpatient care, including psychological / psychiatric
impairment, drug abuse, alcoholism, AIDS, or HIV tests, unless otherwise excluded
here: ____________________________________________________________
I understand that the school district is responsible for maintaining confidential files
for access and review by involved educational staff only. Academic, psychological
and health records are exchanged among California Public Schools. No further
disclosure of this information, by Fresno Unified School District (FUSD), should be
done without specific, written and informed release by parent/legal guardian.
This authorization will expire in 1 year, unless otherwise specified here: _________
Authorization Restrictions and Rights
Signing this authorization is voluntary. You can refuse to sign. Refusing to sign
will not affect FUSD’s commitment to providing a quality education for your child,
however, refusing to sign may inhibit our ability to implement optimal plans of
education, learning accommodations and/or health care plans for your child.
This authorization may be revoked at any time. To revoke this authorization,
you must provide the organizations or individual listed in Section B of this form,
with a written request to revoke the authorization. Any information disclosed
before your written revocation is received, may be used as previously permitted.
You have the right to receive a copy of your “Authorization for Release of Health
Information”. You will receive a copy of this authorization if you request it.
If you authorize disclosure of information to a person or entity that is not legally
required to keep it confidential, the information may be redisclosed and may no
longer be protected by state or federal law.
You may inspect/copy information to be disclosed, as provided in CFR 164.524.
________________________________________________
__________
Signature of Parent / Legal Guardian
Date
________________________________________________
Signature of Witness
HSF-121 (Rev. 1/04)
Side 2 of 2
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