Consent For Exchange Of Information Form printable pdf download

CONSENT FOR EXCHANGE OF INFORMATION

between Child Care Health Consultant and/or Child Care Program and

Other Individuals/Programs/Agencies

(No referral involved)

I understand that information regarding my child is generally confidential and may not be given to employees of other

schools, public agencies or individual professionals in private practice without my consent or other legal requirement.

, hereby consent to the release of the following information

____________________________________________

full name of parent/guardian

initialed and checked below, regarding my child ____________________________________ held by

full name of child

________________________________________________ to _________________________________________.

full name of individual or agency/address

full name of Child Care Health Consultant

____ ❏ Educational/Developmental Records

____ ❏ Diagnostic Assessments/Evaluations

(Occupational/Physical Therapy, Speech and Language Pathology,

Psychological, Social-emotional)

____ ❏ Developmental/Health Screening(s);

________________________________________

please specify:

____ ❏ Medical

____ ❏ Dental

____ ❏ Immunizations Records

____ ❏ Other:

________________________________________________________________

please specify:

I authorize communication and exchange of information between ____________________________________ and

name of individual/agency holding records

_________________________________ to discuss the above indicated records/conditions, and/or findings. I also

name of Child Care Health Consultant

authorize communication and exchange of information between ___________________________________________

name of Child Care Health Consultant

and ____________________________________ Further, ________________________________ is authorized

name of child care program

name of Child Care Health Consultant

to share the information gained with his/her supervisor(s) and/or child care health consulting staff working directly

with her/him. Consent for release of information and authorization of communication shall be for the limited

purpose of understanding and addressing my child’s needs.

This consent is voluntary and I understand that I can withdraw my consent for my child at any time. Unless I

withdraw this consent, this authorization will be effective for the period my child is continuously enrolled in the

_______________________________________

By signing below, I am confirming that I have read,

name of the child care program

understood and agree to the above.

Parent/Guardian Name: __________________________________________________

print full name

Parent/Guardian Signature:________________________________________________ Date:_____________________

NOTE: In accordance with the Health Insurance Portability and Accountability Act (HIPPA) and applicable California laws,

all personal and health information is private and must be protected.

California Childcare Health Program (CCHP) 07/03

Consent For Exchange Of Information Form

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