MASCONOMET REGIONAL SCHOOL DISTRICT

Karen Flom, RN, BSN, NCSN Gwen Lemire, RN, BSN, NCSN

978-887-2323, Ext. 6116, FAX 978-887-7243 978-887-2323, Ext. 6125, FAX 978-887-1991

AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION TO AND FROM SCHOOL DISTRICTS

Completion of this document authorizes the disclosure and/or use of individually identifiable health information, as set forth below, consistent with Federal laws (including HIPAA) concerning the privacy of such information. Failure to provide all information requested may invalidate this authorization.

USE AND DISCLOSURE INFORMATION:

Patient/Student Name: ______________________________________________ / _____________________

LAST FIRST MI Date of Birth

I, the undersigned, do hereby authorize (name of agency and/or health care providers):

(1) _____________________________________________ (2) _______________________________________

to provide health information from the above-named child’s medical record to and from:

________________________________________________________ _________________________________

School District to which disclosure is made Address / City and State / Zip code

________________________________________________ _________________________________________

Contact Person at School District Area code and Telephone Number

The disclosure of health information is required for the following purpose:

________________________________________________________________________________

Requested information shall be limited to the following: o All minimum necessary health information; or

o Disease-specific information s described:

___________________________________________________________________________________________

DURATION:

This authorization shall become effective immediately and shall remain in effect until _______ (enter date) or for

one year from the date of signature, if no date entered.

RESTRICTIONS:

Law prohibits the Requestor from making further disclosure of my health information unless the Requestor obtains

another authorization form from me or unless such disclosure is specifically required or permitted by law.

YOUR RIGHTS:

I understand that I have the following rights with respect to this Authorization: I may revoke this Authorization at any time. My revocation must be in writing, signed by me or on my behalf, and delivered to the health care agencies/persons listed above. My revocation will be effective upon receipt, but will not be effective to the extent that the requestor or others have acted in reliance to this Authorization.

RE-DISCLOSURE:

I understand that the Requestor (School District) will protect this information as prescribed by the Family Educational Rights and Privacy Act (FERPA) and that the information becomes part of the student’s educational record. The information will be shared with individuals working at or with the School District for the purpose of providing, safe, appropriate, and least restrictive educational settings and school health services and programs.

I have a right to receive a copy of this Authorization. Signing this Authorization may be required in order for this student to obtain appropriate services in the educational setting.

APPROVAL: _____________________________ __________________________________ ______________

Printed Name Signature                           Date

______________________________________ ______________________________

Relationship to Patient/Student Area code and Telephone Number

12/10/04