Form Mhd 23 - Hipaa- Compliant Authorization For Exchange Of Health & Educational Information - Milford Health Department

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Milford Health Department
School Health Services
HIPAA- Compliant Authorization for Exchange of Health& Educational
Information
Student Name: _____________________________________Date of Birth__________________
I hereby authorize: Name_______________________________
Address_____________________________
Phone_______________________________
and
School Nurse__________________________
School_______________________________
Phone________________________________
To exchange health information and education information/records for the purpose listed below.
Description:
The health information to be disclosed consists of:
The educational information to be disclosed consists of:
Purpose: This information will be used for the following purpose(s): (circle all that apply)
1. Educational evaluation and program planning
2. Health assessment and planning for health care services and treatment in school
3. Medical evaluation and treatment
4. Other:____________________________________________
Authorization
This authorization is valid for one school year. I understand that I may revoke this authorization at any
time by submitting written notice of my consent. I recognize that health records, once received by the
school district, may not be protected by the HIPAA Privacy Rule, but will become education records
protected by the Family Educational Rights and Privacy Act. I also understand that if I refuse to sign,
such refusal will not interfere with my child’s ability to obtain health care.
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 Connecticut, a competent minor, depending on age, can consent to outpatient
mental health care, alcohol and drug abuse treatment, testing for HIV? AIDS, and reproductive health care services.
Copies: Parent or student*
Physician or other health care provider releasing the protected
health information
MHD 23
School official requesting/receiving the protected health
information

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