Authorization For Release Of Confidential Information

STATE OF LOUISIANA

AUTHORIZATION FOR RELEASE OF

CONFIDENTIAL INFORMATION

TO BE COMPLETED BY PARENT/LEGAL GUARDIAN

PART 1: CONTACT INFORMATION

Student’s/Child’s Legal Name

Date of Birth

Social Security #

Parent/Legal Guardian ______________________________________________

Telephone # __________________

Mailing Address ________________________________________________________________________________________________

PART 2: RECORD REQUEST

Complete box A OR box B below. Both boxes may not be completed on the same form.

Specify the records to be released for the treatment date(s)

If initialed below, I specifically authorize release of the following:

listed below in Part 3

Psychotherapy notes and records indicating

❑ COMPLETE RECORD(S)

❑ Emergency Room

psychological or psychiatric impairment(s)

❑ Discharge Summary

❑ Lab

___________

❑ History & Physical

❑ Pathology

Initials of parent/legal guardian

❑ Operative Report

❑ Radiology Results

❑ Consultation

❑ Other _________

❑ Progress Notes

__________________

❑ Cardiopulmonary

(Indicate EKG, Stress Test, Sleep Study)

PART 3: AUTHORIZATION

This does not authorize the release of the following: drug and alcohol use counseling and treatment and HIV/AIDS and sexually transmitted

disease testing and treatment.

I authorize:

Name: ______________________________________________________________________________________ (School System)

❑ TO RELEASE Information TO

❑ TO OBTAIN Information FROM

AND/OR

(Place an “X” in the box that indicates if the information is being released AND/OR requested.)

Name: __________________________________________________________________________ (Hospital, Physician, Service Agency,

School RN and/or other health provider)

For treatment date(s): __________________________________________________

The information is to be released for the purpose(s) of:

❑ Evaluation to determine eligibility or continued

❑ Designing an individual educational program

❑ Determining appropriate placement for treatment needs

eligibility for special education services

❑ Providing physical therapy treatment

❑ _____________________________________________

❑ Providing occupational therapy treatment

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing

and present my written revocation to the same medical records department receiving this authorization form. I understand that the

revocation will not apply to information that has already been released in response to this authorization. Unless otherwise revoked, 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 in nine (9) months from the date of authorization. An

authorization is voluntary. I will not be required to sign an authorization as a condition of receiving treatment services or payment,

enrollment, or eligibility for health care services. Information used or disclosed by this authorization may be re-disclosed by the recipient

and will no longer be protected under the Health Insurance Portability & Accountability Act of 1996.

________________________________________

_________________

__________________________

Signature of Student or Legal Representative

Date

(Relationship to student)

(Parent/Legal Guardian must sign if student < 18)

________________________________________

__________________

Signature of Witness

Date

Authorization For Release Of Confidential Information - Louisiana

Related Articles

Related forms

Related Categories