Form 581-1196-P Authorization To Use And/or Disclose Educational And Protected Health Information Page 2
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Authorization to Use and/or Disclose Educational and Protected Health Information
Purpose of form:
•
This form was created so that educational agencies could request information from health entities that require HIPAA-compliant
release forms. (HIPAA: Health Insurance Portability and Accountability Act)
•
This form is used when there is a need to obtain consent from a parent, legal guardian or student/child to authorize the named
agency to:
•
Send/disclose protected health information and/or educational information; and/or
•
Receive/use protected health information and/or educational information
Directions for completing form:
Box 1. Required.
•
Enter the student/child’s full legal name including middle name;
•
Enter other names used by the child including nicknames;
•
Enter child’s date of birth;
•
Enter the name and address of the health care provider who will send or receive requested protected health and/or educational
information;
•
Enter the name and address of the school district or EI/ECSE program sending or receiving the requested protected health and/or
educational information; and
•
Check all appropriate boxes that apply indicating which provider is authorized to send and which provider is authorized to receive
protected health and/or educational information.
Box 2.
Required.
•
Mark all the boxes that apply regarding how the requested protected health and/or educational information will be used. For a record
that is not represented in the list, check the “other” box and specify a different type of purpose.
Box 3.
Required.
•
Mark all the boxes that apply regarding which specific medical and/or educational records are being requested. For a record that is
not represented in the list, check the “other” box and specify a different type of record.
Box 4.
Required only if any of the four types of records indicated are requested. This box should be left blank if none of these four types of
records are requested.
•
The four types of records indicated require an additional level of protection. To request any record in Box #4, the specific type of
record must be listed in the spaces provided and the parent, legal guardian or student/child must initial the space before each type of
record requested. For example, for mental health information, a program might indicate “psychologist’s assessment” and then the
parent, guardian or student/ child would initial the space at the beginning of the mental health information line.
Box 5.
Required.
• This box contains information relating to the parent’s, guardian’s, or child’s rights in giving authorization including the right to refuse
to sign, the right to request a copy after signing, the right to inspect the information to be used and/or disclosed, and the right to
revoke the authorization. Information is given that clarifies that when requested information is sent, the laws that protect that
information may no longer apply since the receiving agency may not be bound by the same laws as the sending agency.
• In item c., identify who will receive the potential revocation. The statement clarifies that if an action has already been taken, for
example, protected health information has already been sent, then the revocation for that specific information is not valid. However,
the agency may voluntarily return the information received after the revocation has been signed and submitted.
Box 6.
Required.
•
Parent, legal guardian, or student/child must sign for the authorization to be valid. If parent or guardian, the relationship to the child
must be indicated. The date of the signature must be entered.
•
The authorization is only valid for the purposes checked or stated in the form.
Box 7.
Required.
•
The month, day, and year that this authorization will expire must be included in the space provided. The date must not go beyond
one year past the date of the signature.
Additional directions
•
Place a copy of this form into the student/child’s file.
•
HIPAA requires that the school district/EI/ECSE program give a copy of the authorization form to individuals who sign it and request
a copy. However, it is recommended practice that the school district/program automatically give the parent, guardian, or
student/child a copy of the form after they have signed it, whether or not they request it, so they will have a record of the
authorization.
Form 581-1196-P (Rev. 6/07)
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