Authorization For Release Of Records Information Form printable pdf download

Authorization For Release Of Records Information Form

Lake Washington School District

Authorization for Release of Records/Information

Student: ________________________________________ Birth date:

Grade:

School:

Student No:

PURPOSE OF AUTHORIZATION FOR THE RELEASE OF RECORDS:

As a parent or guardian you have the right to give permission or not give permission for the exchange of your child’s

records with other persons or agencies. This request provides you with the opportunity to approve or not approve such a

request unless release of records is allowed under one of the exceptions under the rules implementing the Federal Family

Education Rights and Privacy Act (for example, transfer of records from one school district to another).

I hereby authorize the mutual exchange of confidential information and the release of records among and

between the Lake Washington School District and the person(s) or agency listed below:

To/From:

From/To:

(Name of agency/person)

(District employee/title and school or department)

Street Address

City, State, Zip

Phone number/Fax number

Check all record types to be released:

Health/medical Records

Psychological and counseling records

Special Education records

Transcripts

Other (specify):

The reason for disclosing the record(s) is:

I understand that the information obtained by the Lake Washington School District will be treated in a confidential

manner under the provisions of the Family Education Rights and Privacy Act (FERPA). FERPA prohibits disclosure of

personally identifiable information without consent except in limited circumstances. Please note that if the request is

for health or medical information, the medical information received by the District is protected under FERPA privacy

standards and not the Health Insurance Portability and Accountability Act (HIPAA).

Note: For release of medical records, the authorization will automatically expire 90 days from the date of signing.

I understand that my consent for the release of records is voluntary, and I can withdraw my consent at any time in

writing. Should I withdraw my consent, it does not apply to information that has already been provided under the prior

consent for release.

Parent/guardian signature

Date

Street address

City, State, Zip

Rev. 6/30/2011

Authorization For Release Of Records Information Form