Authorization For Release Of Protected Education Information Form - State Of Rhode Island And Providence Plantations Family Court

Download a blank fillable Authorization For Release Of Protected Education Information Form - State Of Rhode Island And Providence Plantations Family Court in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Authorization For Release Of Protected Education Information Form - State Of Rhode Island And Providence Plantations Family Court with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

STATE OF RHODE ISLAND AND
PROVIDENCE PLANTATIONS
FAMILY COURT
County
Petition Number
Petitioner
Respondent
AUTHORIZATION FOR RELEASE OF PROTECTED EDUCATION INFORMATION
Respondent Name: _________________________________ Date of Birth: ___________________
Address/Street: _____________________________________________ Apartment No.: ________
City/Town: ____________________________ State: ________________ Zip Code: ____________
I, ___________________________________, authorize the Rhode Island Family Court Mental
(Parent/guardian/eligible student)
Health Clinic to obtain confidential information from:
School
________________________________________________________________
Address
________________________________________________________________
Telephone
__________________________
Facsimile
__________________________
Contact Person
________________________________________________________________
Check confidential information to be released or obtained:
 Complete educational record OR
Specify records:
 Educational evaluations
 Assessments/treatment plans
 Telephone communications
 Educational/Individualized Education Plan
(IEP) information
 Transcripts/report cards
 Information pertaining to my education
 Other (specify)
 § 504 information
___________________________________
Method of Release:  Telephone/Verbal
 Photocopies
 Facsimile (401) 458-3128
The purpose of this information is for: Rhode Island Family Court Mental Health Clinic
Assessment for review prior to the child/family’s appointments with the clinic.
PLEASE MAIL OR FAX ALL INFORMATION TO:
Rhode Island Family Court Mental Health Clinic
c/o Case Manager
One Dorrance Plaza – Room 257
___________________
Providence, RI 02903
Initials Parent/Guardian
Page 1 of 2
FC-16 (revised January 2012)

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Order Acknowledging Paternity - State Of Rhode Island And Providence Plantations Family Court Order Acknowledging Paternity - State Of Rhode Island And Providence Plantations Family Court Legal
Consent Order Form - State Of Rhode Island And Providence Plantations Family Court Consent Order Form - State Of Rhode Island And Providence Plantations Family Court Legal
Application To Clerk For Entry Of Default - State Of Rhode Island And Providence Plantations District Court Application To Clerk For Entry Of Default - State Of Rhode Island And Providence Plantations District Court Legal
Authorization For Direct Deposit - The State Of Rhode Island And Providence Plantations - Department Of Human Services Office Of Child Support Services Form Authorization For Direct Deposit - The State Of Rhode Island And Providence Plantations - Department Of Human Services Office Of Child Support Services Form Legal
Form 632 - Limited Liability Company Annual Report For The Year - Secretary Of State, State Of Rhode Island And Providence Plantations Form 632 - Limited Liability Company Annual Report For The Year - Secretary Of State, State Of Rhode Island And Providence Plantations Legal
Form Exo-app - Sales & Use Exemption For An Exempt Organization - State Of Rhode Island And Providence Plantations Form Exo-app - Sales & Use Exemption For An Exempt Organization - State Of Rhode Island And Providence Plantations Legal
Form 101 - Business Corporation Articles Of Amendment To The Articles Of Incorporation - State Of Rhode Island And Providence Plantations Form 101 - Business Corporation Articles Of Amendment To The Articles Of Incorporation - State Of Rhode Island And Providence Plantations Legal
Form 203 - Articles Of Dissolution - State Of Rhode Island And Providence Plantations Form 203 - Articles Of Dissolution - State Of Rhode Island And Providence Plantations Legal
Form Ri-7695e - State Of Rhode Island And Providence Plantations Research And Development Expense Credit - 2013 Form Ri-7695e - State Of Rhode Island And Providence Plantations Research And Development Expense Credit - 2013 Financial
Form 631 - 2002 - Non-profit Corporation Annual Report - State Of Rhode Island And Providence Plantations Form 631 - 2002 - Non-profit Corporation Annual Report - State Of Rhode Island And Providence Plantations Legal

Related Categories

Parent category: Legal
Download
Go
Page of 2