5141.21 Form #6

_________________ PUBLIC SCHOOLS

_______________, Connecticut

   HIPAA-Compliant Authorization for Exchange of Health & Education Information

Patient/Student Name: ___________________________________________________ Date of Birth: _____________________________

I hereby authorize ______________________________________________ [insert health care provider name & title] and

_______________________________________________________________ [insert address & telephone of school/school district]

___________________________________________________________[insert address & telephone of health care provider]

Description:

The health information to be disclosed consists of:

The education information to be disclosed consists of:

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

[ ]   Educational evaluation and program planning

[ ]  Health assessment and planning for health care services and treatment in school

[ ]  Medical evaluation and treatment

[ ]  Other:

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 health 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.

Parent Signature:  _________________________________________________________  Date:  _________________________

Student Signature*:  _______________________________________________________  Date:  _________________________

*  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 Connecticut, a competent minor, depending on age, can consent to outpatient mental health care, alcohol and drug abuse treatment, testing for HIV/AIDS, and reproductive health care services.

Copies:  Parent or student*

Physician or other health care provider releasing the protected health information

School official requesting/receiving the protected health information

Developed collaboratively with: CT State Department of Education & CT Chapter, American Academy of Pediatrics