Hippa Compliant Authorization For Exchange Of Health And Educational Information Form

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Beaver Dam Unified School District
Pupil Services Department
HIPPA Compliant Authorization for Exchange of Health and Educational Information
This form authorizes the two agencies listed below to exchange information from the
records of: Name:___________________________DOB:_________________
Agency 1
Agency 2
Beaver Dam Unified School District
_____________________________________
705 McKinley Street
and
_____________________________________
Beaver Dam, WI 53916
_____________________________________
Purpose of this disclosure:
Educational Evaluation &
Health Assessment & Planning for Health
Program Planning
Care Services and Treatment in School
___________________________
Medical Evaluation and Treatment
Other
The information to be released may include:
Psychological Evaluation
Educational Evaluation
Social History
Special Education Record
Psychiatric Evaluation
Treatment Recommendation
School Behavioral & Progress Record
Alcohol or Drug Abuse Information
Patient Health Care Records - Information to be disclosed consists of:____________________________
_______________________________________________________________________
_______________________________________________________________________
Authorization
This authorization is valid for one calendar year. It will expire on
______________
[insert date]. I
understand that I may revoke this authorization at any time by submitting written notice of the withdrawal of my
consent and that the written revocation must be given to the agency/organization I authorized to release
information. I recognize that health records, once received by the school district, may not be protected by the
HIPAA Privacy Act and may become education records protected by the Family Educational Rights and
Privacy Act (FERPA) with additional protection afforded by Wisconsin Statutes 118.25(2m)(a)(b) and 146.82-
146.83. I also understand that if I refuse to sign, such refusal will not interfere with my child’s ability to obtain
health care.
Information beyond date of signature may be released.
Faxes/copies of this release are
acceptable as original.
_________________________________________
_______________________________________
Parent Signature
Date
Student Signature
Date
*If a minor student is authorized to consent to health care without parental consent under federal or state law, only the
student shall sign this authorization form. In Wisconsin, a competent minor, depending on age, can consent to alcohol
and drug abuse treatment, testing for HIV/AIDS, and family planning services.
9/05 A signed copy of this authorization should be kept with the student's records.

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