Hipaa Release Form Columbus Public Schools printable pdf download

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

Columbus Public Schools (CPS)

PART I

Identification

Student’s Name_______________________

Social Security Number or Date of Birth ____________

Disclosing Party____________________________________

(Name of Hospital, Clinic, or Doctor)

Part II PART II Authorization for Release of Health Information

I hereby authorize the Disclosing Party and its agents to disclose health information about the Student to CPS.

OU ARE

UTHORIZED TO

ISCLOSE THE FOLLOWING HEALTH INFORMATION

Information about a particular admission, treatment or episode of care. Specify: _____________________

The following health information: __________________________________________________________

All health information about Student and any information requested by CPS

–

OES THIS AUTHORIZATION INCLUDE

¨ Yes ¨ No

Alcohol/drug abuse information if part of the specified record

¨ Yes ¨ No

Mental health information if part of the specified record

¨ Yes ¨ No

HIV/AIDS-related information (including test results) if part of the specified record

¨ Yes ¨ No

Genetic testing information if part of the specified record

¨ Yes ¨ No

Psychotherapy notes (Note – You cannot combine an authorization to disclose psychotherapy

notes with any other authorization.)

? If none, write “none:” _______________________________________

HAT OTHER LIMITATIONS APPLY

: What is the purpose of the disclosure? (Note – If the disclosure is at the patient’s request, simply state

URPOSE

“at the patient’s request.”): Patient’s request.

5. T

(Note: Unless otherwise stated,

HIS AUTHORIZATION IS VALID UNTIL

I request that this authorization be considered as valid for 12 months from date of signature)

DDITIONAL TERMS YOU SHOULD KNOW

1.Not a Condition for Treatment. Refusal to sign this authorization will not affect your ability to receive treatment

from the Disclosing Party. 2.

Further Uses and Disclosures. Health information to be disclosed under this

authorization may be subject to re-disclosure by the recipient and no longer protected by State or federal privacy

laws.

Right to Revoke. You may revoke this authorization at any time by giving written notice to the

Disclosing Party. Your revocation will not be effective to the extent action has already been taken in reliance on

your authorization prior to receipt of your written revocation. 4. Photocopies. A photocopy or exact reproduction

of this signed authorization will have the same force and effect as the original. 5. Keep a Copy. By signing

below, you acknowledge receipt of a copy of this Authorization.

PART III Send Records To CHS at:

Activities Office – Attn: Jon Misfeldt

2200 26

Street

Columbus, NE 68601

For Questions Contact: Mark Brown, Activities Coordinator

Phone: (402) 563-7050 Fax number: (402) 562-7852

Signature of Parent (or Student if 18 years of age or Older)

Date

Contact Information (Address & Phone)

Columbus High School

Form 4

HIPAA Release Form

Hipaa Release Form Columbus Public Schools

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