Form 581-1196-P Authorization To Use And/or Disclose Educational And Protected Health Information


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Authorization to Use and/or Disclose Educational and Protected Health Information
I authorize the following provider(s) to use and/or disclose educational and/or protected health information regarding my child.
(Student/Child’s Name)
(Date of Birth)
(Other Names Used by Student/Child)
(School or Program Name)
Name and address of health care provider authorized to:
Name and address of school/EI/ECSE program authorized to:
Send/disclose protected health information
Send/disclose educational information
Receive/use educational information
Receive/use protected health information
I understand that this information will be used for the following purposes (check all that apply):
Determining eligibility for Special Education, EI/ECSE, or other services
Developing an appropriate Individualized Education
Program or Individualized Family Service Plan
Determining student/child’s current levels of performance
Other (specify):
Developing an individualized health plan
By marking the boxes below, I authorize the use/disclosure of the following specific medical and/or educational records:
Physician’s Eligibility Statement
Educational Information
Psychological evaluations
Health Assessment Statement
IFSP/IEP document
Social work reports
History and physical exam
Clinic records
Entire medical record
Communicable disease(s)
Prenatal information
Progress notes
By initialing the spaces below, I authorize the use/disclosure of the following information. Specific records requested must
be listed below, e.g., assessment, treatment plan, discharge plan.
Drug/alcohol diagnosis, treatment or referral information requested:
HIV/AIDS related records requested:
Mental health related information requested:
Genetic testing information requested:
I understand that:
a. This authorization is voluntary and I may refuse to sign it without affecting my child’s health care.
b. I have the right to request a copy of this form after I sign it as well as inspect or copy any information to be used and/or disclosed under
this authorization (if allowed by state and federal law. See 45 CFR § 164.524).
c. I may revoke this authorization at any time by notifying _____________________in writing. However, it will not affect any actions
taken before the revocation was received or actions taken based on the previously shared information.
d. Federal privacy rules for protected health information apply only to health plans, health care clearinghouses or health care providers. If
I authorize disclosure of medical information to other agencies or individuals the disclosed information may no longer be protected by
federal privacy regulations.
e. Federal privacy rules for education information apply only to schools and EI/ECSE programs. If I authorize disclosure of educational
information to other agencies or individuals the disclosed information may no longer be protected by federal privacy regulations.
I consent to the use/disclosure of the above information. I understand that the use of this information for any reasons other
than the expressed reasons stated above is prohibited. This consent is subject to revocation at any time, except to the extent
that action has been taken based on information that has already been disclosed.
(Signature of Parent, Legal Guardian, Student/Child)
This authorization expires on ____________________ (Month/Day/Year) (not to exceed one year from date of signature above).
Form 581-1196-P (Rev. 6/07)


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