SOUTH BURLINGTON SCHOOL DISTRICT

HIPAA-Compliant Authorization for Release of Health Information

Student Name:___________________________    
Date of Birth: _____________

I hereby authorize ________________________________________________________________

_______________________________________________________________________________
[insert health care provider name, address and telephone] to release my child’s health information/       records for the purpose listed below to:

  ___________________________________________[School official]

  ____________________________________________[School]

  _____________________________________________[School address and telephone]

Description:  
The information to be shared consists of:

Purpose:  
This information will be used for the following purpose(s):

Authorization

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.  I recognize that these 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.

            Signature ____________________________________        Date ___________
            Relationship to student _________________________

Copies:  Physician or other health care provider releasing the protected health information
School official requesting/receiving the protected health information                       Rev. 8/04