Hipaa - Compliant Authorization For Release Of Health Information Form


Shorewood School District
HIPAA – Compliant Authorization for Release of Health Information
Patient/Student Name: ________________________ ________ __ Date of Birth: _____________
I hereby authorize _____________________________________________ ______________________
[insert health care provider name, address, and telephone]
to release my/my child’s health information/records for the purpose listed below to:
District Nurse
Shorewood School District
1701 E. Capitol Drive
Shorewood, WI 53211
414-961-2888 (office) 414-963-6904 (fax)
The information to be disclosed consists of:
Immunization Record
____X______ Plan of care
____ _____
Other: _____________ __________________________
This information will be used for the following purpose(s):
Determination of immunization compliance
Clarification of child’s needs in school
_____X_____ Other: ___Ongoing medical needs______________________________________________
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 these 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.
Parent Signature
Student Signature*
*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.
Copies: Parent or student*
Physician or other health care provider releasing the protected health information
Rev. 08-2007
School official requesting/receiving the protected health information.


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